Which of the following statements is not an underlying assumption of self management
People with complex chronic kidney conditions such ass ESRD have more difficulties with successful self management
Which of the following is a basic principle of self management
Dealing with the consequences of the illness rather than just the physical disease its self
Andragogy takes into account
That adults desire to take responsibility for what they learn
In order to detect problems as early as possible a thorough evaluation of a new fistula four to six weeks after creation should be considered mandatory
true
Vessel mapping should be performed on all new patients when possible
true
The goal of vascular mapping is to assure that every new patient receives a fistula if possible
true
A juxta-anastomotic stenosis is considered an “outflow” stenosis (inhibits the blood from flowing out of the access vessel).
inflow
The salvage (success) rates for endovascular therapy in early AV fistula failure cases are around 20%.
false 84-98%
Venous stenosis is the most common cause of late fistula loss.
true
Persistent swelling of the access arm and prolonged bleeding after needle withdrawal are signs of an inflow stenosis (inability for blood to enter the access)
true
A secondary AV fistula is defined as a fistula that is created following the failure of a graft or fistula.
true
A catheter that is not able to deliver at least 400 ml/minute should be evaluated for dysfunction.
true
The most serious catheter related complication is infection
true
3 processes that make up the water treatment system
pre treatment,
water-purification,
distribution
3 roles of davitas pnp play
a standard of care best demonstrated practice prima facieevidence
4 ways to prevent contributing to excess blood loss
eveluate effectiveness of of heparin
rinse back blood till lines are pink
hold acess site forappropriate time
dont waste blood in redraws
acronym used when communicating
SMART
simple
meaningful
actual
read
teach
adequacy of dialysis is represented by
kt/v
antibiotic that should be administered over a period of at least 60 min
vancomycin
what factors influence k
bvp
what happens when arterial pressure becomes greater than -260
hemolysis
what happens if total Cl is collected before the minimum time the RO should be operating
rsults could be falsely negative
what happens to the TMP if clotting occurs in the dialyzer
it decrease
what happens when bleach an parecitc acid are mixed
a toxic cl gas is produced
wjat is a good adequacy goal for 3 times per week HD
KTV of atleast 1.2
URR of at least 65%
what is KDQOL 36 used
to asses physical health, mental health effects in dialy living symptoms burden of kidney disease
what not to include in AOR
personal opinion
specu;ation
vendettas
what shou;d you do if pt needs a bathroom break
return blood and recirculate machine
when is a pyrogenic reaction most likely to occur
during the first 45-75 mins
when is risidual bleach testing done
after bleach dis infection and prior to use
when to chart in medical record
change in baseline assesment or pt condition
procedure or treatment
medication administration pt teaching
care plan
when to give hep b booster
when HBsAB drops 10
when to use directing communication
when trainning pts
when to use folowing communication
when pt need time to process or digest something
when to use guiding communication
when creating an action plan
what bacteria requires hand washing instead of alcohol rub
c diff
which direction should arterial needle be placed
anti or retro who cares
which direction should the venous needle be placed
antegrade with flow of blood
who educate pt on treatment modality
neph, SW and CN
to evaluate if pt is stable before discharge
nurse must complete post treatment assessment
pre treatment required by nurse?
if abnormal findings
for AKI pt pretreatment always required
if a pt with acute kidney injury dialyses in the out pt facility one task of the pt care TM is to monnitor blood pressure and weight closely why?
HYPOvolemia and HYPO tensives episode can cause RENAL ISCHEMIA and can further damage the kidneys
CKD can have its origin pre renal, intra renal, or post renal. which of the following conditions is an intrs renal cause of CKD
hypertension
pt with cardiac disease are ten times more likely to experience intradailytic hypotension
LVH
offering a pt this is an example of sodium loading
broth
what is an intra cellular or intersistial symptom of fluid overload
edema
this electrolyte is often elevated in pts who experience severe itching
phosphorus
the kidneys help regulated BP with this
renin
this hormone stimulates the bone marrow to make red blood cells
erythopoieten
this electrolyte aids in clotting, nerve impluse transmission, muscle contractions and bone formation
calcium
restless leg syndrome is a symptom of which complications in CRF
peripheral neuropathy
what is classified as a bone disease associated with renal failure
CKD-MBD
the kidneys convert Vitamin D into which hormone
calcitrol
these procedures can cause significant blood loss in our patients
access
maintaining normal serum calcium levels is the primary function of this hormone
PTH
this disease is the leading cause of death in patients at all stages of CKD
cardiovascular
the transport mechanism when particles move from an area of higher solute concetration to an area of lower solute concentration is called
diffusion
during dialysis the movent of bicarb from the dialysate into the blood
helps normalize ph
the kineys excretory function include
nomalizing electrolytes
chlorine/chloramine testing can be found in
the sample port from the primary carbon filter
hardness testing removes
calcium and magnesium
excess calcium and magnesium in water used for dialysis
muscle weakness
what removes chlorine and chloramines
carbon tanks
arterial pressure more positive
seperation of blood tubing from arterial access
venous pressure more positive
clotting in drip chamber
venous pressure more negative
severely clotted dialyzer
role davitas pnp play
best demonstrated practice
standard of care
purpose of DQI
encourage continuous improvement accross a broad range of disease management
consequences of fluid overload
increased mortality
consequences of hypovolemia during treatment
ischemia and damage to vital organs
KDQOL 36
identifies barriers
hyperkalemia
muscle weakness abmormal HR
4 key elements affect CKD MBD
soft tissue calcification
ultrafiltration
fluid forced through semipermeable membrane
covection
slolutes and solvent move
vtags
state specific regulations to be met with a condition such as infection providing interpretive guidance for each regulation
when is the pretreatment assessment by the licensed nurse required
when it is mandated by the state
when the pct performing a data collection notices abnormal findings
when the patient reports unusual symptoms to the nurse prior treatment initiation
when the nurse observes unusual behaviors in a patient entering the treatment floor
ALL OF THE ABOVE
data collection
heart rate:72
fluid overload and hypertension lead to LVH this means
hypotensive episodes are more likely to occur during treatment
your role in ckd-mbd management includes
reminding the patient who is eating a snack during dialysis to take his phosphate binders
your role in anemia management
rinsing back as much as other patients blood as you can at the termination of each treatment
What is important when monitoring weight and BP for acute patients?
keep patients wet to avoid hypotensive episodes
What do you need to consider in regards to acute patents vascular access?
Usually have a CVC
- follow policy and procedure to prevent infections
Why is it important to know what caused your patient’s CKD?
to inquire about possible problems during data collection and assessments
Kt/V: What is K?
clearance of urea
What treatment factors decrease K?
not waiting 3-5 minutes after giving heparin with treatment initiation to prevent clotting
What factors influence V (volume)?
sex, age, weight, height, amputations
Needle gauge and suggested BFR
17: 200-250
16: 250-350
15: 350-450
14: >450
What do you do if a patient wants to get off early?
educate and document, still draw lab on habitual patients, MUST NOTIFY NURSE
Lab draw mistakes that would falsely increase Kt/V
not waiting the full 15 seconds to draw the BUN
What is the role of the PCT prior to treatment initiation?
DATA COLLECTION
Squeezing the BP cuff can damage the machine: T/F
True
4 reasons we document in the medical record
- proof that care was rendered
- provides data continuity and planning of patient care
- permanent legal record
- communication tool
Pre-treatment patient data collection/assessment
Data collection: before initiation
Assessment: 30 minutes into treatment
Post treatment data collection/assessments
after treatment
-NOT DURING RINSEBACK
What are possible consequences of poor or incomplete documentation
attack on your care
What are the six items included in charting administered medications?
REASON FOR ADMINISTERING
What are the 5 W’s to be used when completing an AOR
who should report an AOR
what type of incident
when should it be reported
where should they be reported
why
What are the four consequences of sodium loading during dialysis?
Thirsty
Increase Fluid Intake
Increased intradialytic weight gain
Increased ultrafiltration rate
What is the purpose of UF profiling?
fit to the patient to prevent crashing and allow for vascular refill
Why do we measure the pH in the dialysate
to verify acid-base balance is within an acceptable range
Conductivity and pH alarm causes
no concentrate
improper bicarb
calcium or magnesium precipitate
line of filter occlusion from debris
improper calibration
Temperature alarm causes
lower temperature, increases BP
hemolysis occurs at 42 degrees calcium which releases potassium
Power
the appropriate intervention is to remove venous line from air detector clamp before starting hand crank
Arterial Pressure High alarm causes
separation of tubing
Venous pressure high alarm causes
kink in tubing
infiltration
clotting in the venous drip chamber
Davita Quality Index
the purpose of selecting the component measure for DQI is to encourage continuous improvement across a broad range of disease management processes
DQI success is achieved by
-managing individual patients first and allowing scores to follow
-knowing each team members role and improving DQI scores
-using the CQI (continuous quality improvement) process to help identify trends and make improvements
(answer all of the above)
Importance of P&P
when supervising non-licensed, assistive personnel, it is the responsibility of the licensed nurse to ensure these teammates also meet the standard of care
What are the risks of doing it your way
it can lead to civil liability
What makes dialysis patients more susceptible to HAIs?
they have weakened immune systems and prolonged access to blood
Why are dialysis patients at increased risk for acquiring a HAI at the facility?
CONTACT TRANSMISSION
what is the most common transmission route for HAIs?
contact transmission
What is the most important intervention you can do to prevent HAIs?
Hand washing
What is the most common infectious complication in hemodialysis patients?
Per the CDC, the most common factor contributing to bacteremia is CVC
What germ causes the most common infections in hemodialysis patients?
MRSA
Why is wearing gloves so important?
Decreases risk of hand contamination
Who can use sinks designated for hand washing?
clean sinks must be dedicated for hand washing only
What is the correct procedure in regards to your hands when you have casual contact with a patient?
don’t need to have gloves but must perform hand hygiene before caring for patients
Successful Lab draws
know the 20 tips
-follow the order of the lan draws to prevent specimens from being contaminated with other tube additives
-double labeling tubes prohibits processing
rules for spinning samples
only spin tubes of same kind, size, and fill level and should be placed opposite of each other
hyperkalemia
potassium above 6.5
extreme muscle weakness
cardiac arrest
What is the primary cause patients are anemic?
decreased production of Erythropoietin
How can you print contributing to blood loss?
adequate heparinization
What is pericarditis?
inflammation of sac around the heart
What is included in pericarditis treatment?
RESTRICTION OF HEPARIN
more/adequate dialysis
What to use for Dry, itchy skin
hyper fatted soaps and lotions
Peripheral neuropathy
educate patient about good shoes, look at feet, don’t go barefoot
-can’t feel sores
What are the four key elements affected in CKD-MBD?
calcium
phosphorus
parathyroid hormone
calcitriol (vitamin D)
What are symptoms of CKD-MBD in addition to bone disease?
severe itching, muscle weakness
CALCIFICATION OF SOFT TISSUE
What is your role in CKD-MBD management?
encourage patients to take binders with their food!
talks to patients and listen to them!
What does the acronym DARN stand for?
Desire to change
Ability to understand
Reason to change
Need
What’s the best way to help patients successfully change behaviors?
Inspire behavioral change through support, compassion and empathy
When should the communication style “Directing” be used?
when training to perform procedures
What are the three core communication skills to be used within the communication styles?
Asking Listening Informing
Righting Reflex
Intervention of a healthcare practitioner who observes a patient doing something detrimental to their health
Summarizing
includes the main aspects of what was said during the conversation
The 5 stages of grief
Denial
Anger
Bargaining
Depression
Acceptance
Is there an order to work through the five stages of grief?
No
what is KDQOL 36
an assessment tool for the social worker to identify barriers
-the social worker compiles the results and develops goals with the patient
Who is the social worker available for?
Caretakers struggling to meet demands of the patient’s treatment regime
Ultrafiltration
(only fluid)
controlled fluid removal by manipulation of hydrostatic pressure
Convection
(solutes and fluid)
solutes are dragged across the semipermeable membrane along with fluid
Diffusion
(solutes)
particles move from an area of high concentration to an area of low concentration
Osmosis
(fluid only)
fluid moves from lower solute concentration to higher solute concentration
What are the kidney’s endocrine functions?
blood pressure control (Renin)
anemia (erythropoiesis)
activation of vitamin D3 and Ca Regulation (calcitriol)
What is the function of bicarbonate?
acts as a buffer
-diffusion of the bicarb from the dialysate to the blood helps normalize body pH
The 4 indicators of optimal nutrition status
- protein (albumin) 4.0 or higher
- stable/desirable target weight
- appropriate appetite
- adequate fat stores/muscle mass
importance of limiting phosphorous/when to take binders
tingling
bone damage
take with meal
Consequences of organ stunning
hypotension can have many adverse affects including impaired tissue profusion of vital organs and organ injury
Muscles cramps
caused by rapid fluid removal and electrolyte shifts
intervention for muscle cramps
DON’T MASSAGE in case of blood clot
-stretch the affected muscle and turn off UF
Fever and chills
any temp greater than 100 degrees or over 2 degrees of baseline WITH symptoms
pyrogen reaction
endotoxins in the water
seizures intervention
discontinue treatment if seizure is severe or patient does not respond to treatment
Dialysis disequilibrium syndrome prevention
don’t skip treatments
-have to go to hospital to get dialyzed if missed more than two treatments in a row
Symptoms of disinfectant infusion
PAIN AT THE VENOUS NEEDLE
-respiratory distress
tingling around the lips
intervention for chest pain/angina
mild: stop pulling fluid: turn UF off
turn down BFR to 200 so we don’t clot
Air embolism intervention
STOP PUMP
lay patient on left side trendelenburg
what are the three basic principles of self-management
Dealing with the consequences of illness rather than just the disease itself
what is the definition of health literacy?
the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
What are the educational tips for visual learners?
select quiet surroundings
What are the educational tips for auditory learners?
word associations or mnemonics
what are the educational tips for tactile learners?
short lectures with hands on activities and frequent short breaks
at what time are medications containing a preservative discarded?
28 days
how long do we wait after administering the heparin bolus prior to treatment initiation?
3-5 minutes
Explain a reason for Immediate jeopardy (IJ)
insufficient or inaccurate chlorine checks
how to talk to a surveyor or what to do when a surveyor observes you or asks questions
I don’t know the answer, but I will find out
Examples of what not to say to a surveyor
I was never told that
nobody ever told me
explain the four AVF evaluations for maturation based on the KDOQI rule of 6’s
rules of 6’s proved guidelines for a FISTULA
- 6-8 weeks post op
-blood flow of 600
-diameter of 0.6 cm
-can’t be deeper than 0.6 cm below the skin
Water hammer pulse, whistling sound
outflow stenosis = whistling
inflow stenosis = hammer sound
BESTIPS Complications and Prevention: Thrombosis
if using hemostatic sponges, we must remove before sending patient home and cover with sterile gauze
Cannulation site prep
use a tourniquet during cannulation on ALL AV fistula unless documentation for otherwise
Site rotation/ healing time
14 days/2 weeks
chlorine in water used for hemodialysis causes
hemolysis which releases potassium
Chlorine/chloramine testing
can’t be more than 4 hours apart
What is removed in hardness testing?
calcium and magnesium
When do we test for hardness?
at the end of each day
response to final water quality alarm
- put all machines in bypass mode
- notify charge nurse, FA, boomed, Medical director
- if water quality cannot be restored terminate all treatments
How do you know numbing has taken effect?
blanching of skin