Inadequate Heparinization
The adequacy of a dialysis treatment may be compromised by
Post reinfusion and prior to disconnection
Routine post dialysis treatment documentation on the patients dialysis treatment record should include patients blood pressure and temperature both
Chemical content
Individual acid containers should be labeled with
Notify the RN
The patient complains of pain at the catheter exit site. What would the PCT do first?
Hemosafe is in place and secure on the arterial line (hemosafe clamp should be secured on the venous line)
Which of these findings noted on a safety check would indicate that an intervention is needed.
Notify the RN
The patient presents to the dialysis center with a pulse rate of 44/bpm but doesn’t appear to be in distress. What should be the dialysis technicians immediate action?
Assessment for possible clotting in the dialyzer
Documentation and interpretation of the KECN (clearance effective by conductivity) results can assist the staff member in
Circulation of water during the day only
Which of the following would minimize bacterial growth in the water treatment system?
Pressure
A major factor affecting ultrafiltration is
Palpating for a thrill
Pre-treatment evaluation of an internal vascular access includes
Hypotension
A patient having a dialysis treatment complains of feeling dizzy, and begins to yawn. These symptoms are most likely to indicate that the patient has
Check the dialysate effluent with a blood leak test indicator
If a blood leak detector alarms a second time and no visible blood is noted, what should the PCT do next?
Surface area of the dialyzer
Which has the most impact on dialyzer clearance?
Turn the blood pump off, clamp the venous line.
The patient exhibits signs of hemolysis. What is the appropriate action to take?
Calcium and magnesium
Softener tanks remove
Technical must perform a functional test on the machine.
During dialysis a patient has a cardiac arrest. Which action should be completed on the dialysis machine before the machine is used by another patient?
Low clearance, hold heparin dose
The following KECN’s are noted: the results indicate a
Time KECN. TIME KECN
00:15. 268. 01:45. 243
00:45. 254. 02:15. 240
01:15. 242. 02:45. 238
Either with or against the flow of blood
The arterial needle is placed
Priming the dialyzer venous end up
An important factor in achieving adequacy during machine set up is
Ultra Care
The FMC program that utilizes technology to improve our patient care is
Bicarbonate
The component of the dialysate that helps treat acidosis is
Check the patient blood pressure
The PCT notices the patient yawning toward the end of treatment. The PCT should take which action immediately
Presence of endotoxins in the dialysate
Several patients with normal pre-dialysis temperatures develop sudden chills and a spike in temperature. This situation is most likely caused by
150 ml/min
What is the correct blood flow rate for priming the dialyzer
Use of a tourniquet is optional when cannulating a new AVF
What is NOT true when cannulating a new AVF?
Weekly
If bicarbonate concentrate jugs are used, the frequency for disinfecting jugs is
Aid in fluid removal
Using the sodium variation module during the dialysis treatment will
To improve nutritional status and ensure compliance with oral intake and reduce the risk of morbidity and mortality
Oral nutrition supplements are given to FMS in-center dialysis patients who are malnourished while they are at the dialysis facility for what reason?
Elevated potassium levels may cause changes in heart rhythm
When instructing patients with CKD, who are receiving dialysis, the RN should include the fact that
Sitting blood pressure followed by the standing blood pressure
One way to establish a patient has orthostatic hypotension is to obtain a patients
Albumin, Hgb, Phosphorous, Adequacy, Catheter Rate
The QSR is a monthly report detailing quality outcomes as primary or secondary. Primary quality outcomes are those that have the highest impact on patient survival. These include
Clamp the venous line
Dialysis has been initiated on a patient using a right internal jugular catheter, as the blood pump is turned up to 200 ml/min, foam begins to accumulate in the lines. The patient begins to wheeze, and becomes short of breath. The care givers FIRST action would be to
Disinfect with 1:100 bleach water and rinse with RO water until negative for bleach
If the bicarbonate jugs have been in storage and are needed for emergency use, what action must be taken prior to use?
Less than 0.10 ppm
According to FMS policy, the safe level for total chlorine is
Bananas, orange juice, and salt substitute
What has the highest potassium content
Remote Total Dissolved Solids (TDS) alarms in treatment room
What notification process would alert the staff of poor water quality during the dialysis treatment
After the completion of the last patient treatment
Following FMC policy, when should the second hardness test be completed
10 minutes
According to AAMI standards the required exposure time of water to the carbon filters to effectively remove chlorine and chloramine is
Notify the RN in charge to stop treatment
If the second GAC (carbon) filter exceeds the acceptable limit for total chlorine, what is the next step?
Hypotension
Excessive fluid removal during dialysis, combined with the patients taking an anti hypertension medication may result in the patient having
Should be engaged before removing the needle from the patient access
When removing needles from an internal access the needles safety device
Turn off ultrafiltration rate
To properly collect a post BUN sample, it is necessary to
Gloves, full face shield or mask and protective eyewear with side shield and fluid resistant gown
What PPE is required when performing venipuncture?
Solution to conduct an electrical current
Conductivity is best described as the ability of a (n)
Inspect the dialysate effluent for pink or red tinged color
The patients blood leak detector alarms. After verifying the blood pump has stopped, what should the PCT do next?
Total Dissolved Solids (TDS)
What reading on the reverse osmosis (RO) machine indicates the level of water quality?
0.10 ppm
Which total chlorine reading is UNACCEPTABLE?
The patient does not respond to verbal questioning and vital signs are trending down.
The PCT observes a patient at the 30 minute safety check. What signs or symptoms will prompt the tech to wake the patient for further evaluation?
Hemolysis
A patient begins to experience shortness of breath, chest pain, and sudden hypotension, the blood is bright red and translucent. The complication most likely occurring is
The top level of the salt pellets in the brine tank must be maintained above the level of the brine solution in the tank
What is the correct level for salt in the brine tank?
Examine both patient arms for the presence of an access
Prior to applying the blood pressure cuff on a new patient, the PCT should
Chlorine and chloramines
The carbon tank removes
Hazardous materials identification system (HMIS) labels
Individual bicarbonate containers must be labeled with
Received from the water supplier to make product water for dialysis
Source water is
Dialyzer primed at 300 ml/min
What factor is most likely to affect dialysis adequacy
Kink or obstruction after the dialyzer
If the arterial pressure changes from -200 mmHg to -250 mmHg from the initiation of treatment, what would be a possible cause?
15 minutes
How long must the reverse osmosis machine (RO) run prior to collecting samples for water testing?
Hemolysis
Blood pump occlusion and kinked lines would most likely cause which complication during hemodialysis?
1:10 bleach water solution
What solution should be used to disinfect a large blood spill area (greater than 10 mLs)
Which letters in the acronym COLT
List three blood borne pathogens
HIV
Hepatitis B
Hepatitis C
What is hepatitis?
Inflammation of the liver
How is hep a transmitted?
Contaminated food and oral-fecal route
How is hep B and C transmitted?
Exposure to blood and body fluids of an infected person
How long can hep b live on surfaces for?
Seven days
When caring for HBV patients staff should NOT
Take care of hepatitis susceptible patients on the same shift at the same time
Why do we dialyze hep c in the clinical area and not in isolation?
Not as contagious as hep B
What blood test indicates infection with Hep B?
HbsAg
Indicates viral presence
Tests for the antigen
What blood test indicates immunity against hep b?
HbsAb
Indicates presence of immunity
What vaccine provides long term immunity to hep b?
Recombivax
Engerix
S/S of TB
Night sweats
Productive, persistent cought
Unexplained weight loss
Chills
Fever
Blood tinged sputum
How is TB spread?
Droplet
What can live outside of the body for seven days? How are they spread?
MRSA
VRE
Spread through contaminated hands of health care workers
What assures that MRSA patients are no longer actively infected?
Three consecutive cultures come back negative
Precautions to take when caring for MRSA/VRE?
Contact
How to seat VRE patients
In the same cohort as people with the same bacteria
How long should you wash your hands for? With alcohol?
40-60 seconds soap and water
20-30 seconds alcohol
What is urea?
A by product of protein metabolism
What is creatine?
A by product of muscle metabolism
What is uric acid?
Occurs naturally in the human body as a result of the metabolism of purine
Purine is from dietary intake or the breakdown of the bodies own cells
What does the nephron do?
Filters blood to form urine
What performs the first step in filtering blood?
The glomerulus
Which of the functions of healthy kidneys can be replaced by dialysis?
Removal of waste products
Regulation of fluid balance
What is renin?
Regulates blood pressure
Sodium and potassium balance
Three common causes of renal failure
Diabetic neuropathy or glomerulosclerosis
HTN causing nephrosclerosis
Glomerulonephritis
S/S of uremia
Yellow-gray appearance
Headache
weakness
fluid overload
anemia
Elevated BUN and creatinine
Itching
Changes in mental status
Normal GFR
90+
Mildly reduced GFR
60-89
Moderately reduced kidney function
30-59
Severely reduced kidney function
15-29
Very severely reduced kidney function
less than 15
Why are renal patients acidotic?
Kidneys control acid/base balance
Hydrogen builds up due to lack of bicarb
What needs to be considered when giving meds?
Decrease elimination due to loss of kidney function
Potential toxicity
Increased potency/duration
Increased frequency
Phosphate binders
Tums
Amphojel
Alucaps
Renagel
Renvela
Phoslo
What is hectoral, calcijex, and zemplar?
Help absorb calcium
Reduce PTH
What is the desired hemoglobin level for hemodialysis patients
10-11
What med is seen to slow progression of kidney disease?
Lisinopril
beta blocker
How do you check blood sugar levels?
From the arterial port
What controls the bodies homeostasis?
Electrolytes
What are the most important electrolytes to consider in uremic patients?
Sodium
Potassium
Calcium
Phosphate
Magnesium
Bicarb
What is normal blood pH?
7.35 to 7.45
What is added to dialysate to maintain a patients ph?
Bicarb
Hypertonic
Contains more particles
Hypotonic
Contains less particles
When does diffusion cease to occur?
Until the concentration of each electrolyte found in the patients blood is equal to the electrolyte concentration in the dialysate
Why is dextrose added to the dialysate?
To prevent hypoglycemia
What is the purpose of checking the dialysate?
That it is compatible with human pH
Conductivity and temp to prevent hemolysis and crenation
Name four ways dialysate is checked
pH
conductivity
temp
check for chlorine after weekly disinfectant
What should the temp be?
36-39
Set by an MD
Why do we use a biocompatible membranes in the dialyzer?
Closer to human cells and tissues
less of an immue response
How to select a dialyzer for a patient
Size
Clearance needs
UF needs
Membrane biocompatibilty
Dialyzer sensitivity
Sneezing
Itching
Rash
Hives
Fever
Pain at the access site
Chest pain
Usually within the first half hour
Using one sterilized with an electron beam
How is the blood compartment separated from the dialysate?
Semi-permeable membrane
What is a semi-permeable membrane?
Only certain molecules can fit through the pores
Molecules larger than the pore size will not fit
Red blood cells and proteins are too large to pass through
What can pass through the semi permeable membrane
Urea
Sodium
Potassium
Water
What should be checked before machine set up?
Dialyzer for sterility
Why does the dialysate flow bypass the dialyzer?
Temperature
Conductivity
Dialysis flow rate
TMP
Blood leaks in the dialyzer
pH measure
What happens if you prime the machine higher than 150 ml/min
Gas vapor lock
Not all the fibers open
How long can a dialyzer recirculate with saline before it is considered unsafe to use?
Four hours
What three processes occur in the dialyzer simultaneously?
Osmosis
Diffusion
Ultrafiltration
What is ultrafiltration in dialysis?
The use of more than one type of pressure, positive and negative, to remove fluid
How do blood and dialysate flow travel through the dialyzer
Countercurrent flow
Blood flows down (arterial to venous)
Dialysate flows up (venous to arterial)
How to tell if your dialyzer is clotting
Rising TMP
Rising venous pressure
Dark blood in dialyzer
Air detector alarms
Heparin
Heparin does not dissolve clots
Anticoagulant effect 5-10 minutes after injection
90 minute half life
After heparin is given, how long must you wait before starting the treatment?
3-5 minutes
When might the heparin dose be decreased?
Treatment time and dialzyer size is reduced
When might the heparin dose be increased?
When a patients KECN is decreasing
Signs of clotting
Infection or fever
What circumstances would contraindicate the use of heparin?
Actively bleeding
Post-surgery or dental procedure
Allergy/sensitivity
Scheduled for surgery
How long can a patients blood be recirculated during treatment interuption?
May lose oxygen after 15 minutes
Why do transducers have to be blood and fluid free?
To get accurate arterial and venous pressure readings
What does pre pump arterial blood flow measure?
The amount of pressure and the quality of blood flow from the access to the blood pump
What must be removed when hand cranking?
The venous tubing
Renal patient temperature
96.4-98.9
Many patients have below normal body temp
Elevated pre temp could mean infection
1 kg =
1000 cc
2.2 lbs
1 oz =
30cc
I liter =
1000 cc
What tells us the EDW is too low? Pulling off too much?
N/V
Dizziness until next treatment
What tells us the EDW is too high? Not pulling off enough?
HTN
Headaches
SOB
Edema
What should the TW include?
Available weight plus prime, rinse back, blouses, and other fluids given during treatment
What is considered the best adequacy monitoring method?
Urea kinetic modeling
What is double pool or eKt/V?
Volume of urea in both the intracellular and extra cellular compartments
Entire body accounting for all body fluid compartments
Minimum of 1.2
What is the molecular weight of sodium and urea?
58-60 daltons
What does KECN stand for?
Clearance effective by conductivity sodium
What is the normal KECN range?
200-300
What should the KECN be less than?
The blood flow rate
What is the KECN is less than 150?
Poor clearance
Will not be used to generate an OLC volume
What if the KECN is greater than 350?
May need temp change and conductivity recalibrate
How long should blood tubes spin for?
10 minutes
When is lab work drawn and from where?
Before giving heparin
From the arterial line
Disadvantage of an AV fistula?
Takes longer to mature 1-4 months
Disadvantages of a graft
Bleed more
More prone to infection
Why is it better to conduct access flow testing at the start of treatment?
Patients are more hemodynamically stable
Not affected by ultrafiltration
What can cause an access to clot?
Hypotension post treatment
What to look for in an internal access pre and post treatment?
Bleeding
Swelling
Bruising
Redness
Drainage
Thrill and bruit
What direction should needles be placed for optimal flow?
Venous in the direction of blood flow
Arterial can go either way
What is steal syndrome?
Arterial blood being shunted into the venous circulation through the anastomosis
Reduction of blood flow (ischemia) to the extremity
Distal to the access
pain, tingling, numbness, cold, cyanotic hands or nails
Where do catheters sit?
In the right atrium of the heart
How can you manage poor catheter flow during treatment?
Lower the patients head
Have the patient cough
When is cramping seen?
Middle to end of treatment
What do you NOT do for cramping?
MASSAGE
How to test for hemolysis
Take blood from the venous port
If blood is red or pink after the centrifuge it is positive
S/S of crenation
Dark opaque blood
SOB
Chest pain
What is pericarditis? S/S?
Inflammation that surrounds the heart due to fluid and waste build up
Fever
Chest pain
Pericardial friction rub
What is a pyrogenic reaction? S/S?
Reaction to pyrogens (foreign bodies, endotoxins) that cause a reaction
Subside suddenly one hour intro treatment or after treatment ends
Fever, chills, low BP