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What are the functions of a healthy kidney? CORRECT>>- REGULATE, SYNTHESIS, ENDOCRINE: Regulate fluid balance, blood volume, electrolytes, acid-base balance, synthesize calcitrol (active vitamin D), secrete erythropoietin and release renin what is the glomerular filtration rate in the five stages of kidney disease? CORRECT>>- flow rate of filtered fluid through the kidney stage 1: 90+ stage 2:60- 89 stage 3: 30 - 59 stage 4: 15 - 29 stage 5: < what are the types and stages of kidney failure? CORRECT>>- acute renal failure: sudden onset, severe, usually reversible. can be caused by drug toxicity, dehydration, or motor vehicle accident Chronic renal failure: slow onset, progressive, permanent. can be caused by diabetes, hypertension, or genetic disease such as glomerulonephritis or nephrosclerosis what are the signs and symptoms of renal failure or uremia? CORRECT>>- elevated serum levels of BUN/Creatinine, phosphorus, potassium. anemia, nerve damage, yellow-gray appearance of skin, fluid overload, dyspnea, edema, hypertension, proteinuria, uremia, lethargy, weakness, headache, itching, fatigue, nausea restlessness, mental change, loss of appetite. what is anemia and how is it treated? CORRECT>>- lack of RBC (decreased or lack of erythropoietin production). iron binds with hemoglobin in RBC and transports oxygen. it is treated using erythropoieting stimulating agents and usually administered IV. which of the functions of healthy kidneys are replaced by dialysis? CORRECT>>- removal of waste products and regulation of fluid balance. dialysis does not regulate endocrine production
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list briefly and describe three modalities of treatment for end stage renal disease CORRECT>>- Hemodialysis: uses vascular access to draw blood from patient and send to dialyzer and into semipermeable membrane where diffusion removes waste products and ultrafiltration removes fluid. provides approximately 15% of the normal function of the kidney. peritoneal dialysis: continuous cycling peritoneal dialysis and continuous ambulatory peritoneal dialysis. both types use permanent catheter in highly vascularized peritoneal cavity. dialysate is infused into peritoneal space and allowed to dwell and then drained. excess fluid and waste is removed through osmosis and diffusion what is the difference between hemodialysis and peritoneal dialyisis? CORRECT>>- Hemo: outpatient, dialyzer is used to remove waste from blood via diffusion and fluid is removed through ultra filtration. peritoneal: home setting, peritoneal membrane is the semipermeable membrane that filters waste and fluid removal occurs via osmotic pressure and concentration gradients caused by the dextrose solution and dwell times. when is it known that a patient has developed sensitivity to a dialyzer? CORRECT>>- seen within the first half hour of treatment. sneezing, itching, pain at access site, chest pain, rashing, hives, fever are symptoms. alarm conditions CORRECT>>- Blood: blood leak, air detector, venous/arterial pressure, TMP. stops the blood pump therefor blood is not cleaned and no ultrafiltration. potential for clotting due to stagnant blood Dialysate: conductivity high/low, temperature. dialysate goes into bypass so no cleaning of blood. uf continues. what are the body fluid compartments? CORRECT>>- 50 - 70% of body is water. intracellular, extracellular, intravascular, interstitial. what is diffusion CORRECT>>- movement of solutes across semipermeable membrane from high concentration to low concentration. solutes include urea, electrolytes, creatinine, drugs what is osmosis? CORRECT>>- movement of fluid from lower concentration of solutes to a higher concentration. what is ultrafiltration? CORRECT>>- use of both negative and positive pressure to pull excess fluid from the patient why is water used for dialysis treated? CORRECT>>- water contains contaminants, electrolytes, and impurities. these must be removed bc the patients are exposed to large volumes of water during tx what is chloramine and how is it different from chlorine CORRECT>>- combination of chlorine and ammonia what is the diasafe filter? CORRECT>>- found on back of hemodialysis machine that allows for the delivery of ultrapure dialysate.
4 ways dialysate is checked to ensure safety CORRECT>>- ph, conductivity, machine temp, negative residual chlorine after machine disinfection and before first treatment after disinfection how is dialysis delivered? CORRECT>>- The Hemodialysis Machine. two sub sections: blood delivery system (circulates pt blood) and dialysate delivery system (mixes and circulates dialysate) when are bloodlines replaced? CORRECT>>- when contaminated (dropped on floor or placed in prime bucket with open ends), clotted (line or drip chamber), or found defective what causes increased arterial and venous presssures? CORRECT>>- kinks, bfr exceeds vascular access flow, incorrect needle gauge size compared to bfr, needle placement, clotting stenosis, vasoconstriction of vasospasms, malposition of catheter tip, hypotension, poor cardiac output (increased blood viscosity due to high hgb or ultrafiltration) how do you test for a small blood leak? CORRECT>>- dipping test strip into dialysate obtained from outflow (arterial/red). test strip will change color if positive for blood. do not return blood if test is positive or if ther are visible signs of blood in dialysate. how is a large/major blood leak treated? CORRECT>>- dialysate will apear bloody or blood tinged. do not return blood. what are the two most commonly changed electrolytes in dialysate/ CORRECT>>- potassium and calcium- makes changes based on pt's current monthly lab results steps for treating an infiltrated access CORRECT>>- 1. establish that infiltration has occurred
- sto pdialysis turn off blood pump, clamp bloodlines.
- notify rn
- disconnect bloodlines from fistula lines and recirculate blood. flush non-infiltrated needle with normal saline
- if infiltration occurred after heparin administration: cap end of needle and secure (to be removed at end of tx). apply ice
- if fistula is infiltrated, rest fistula for one treatment when ordered by nephrologist. next cannulation should be above infiltrate
- instruct pt to apply ice for 24 hours and watch for complications such as (pain, reoccurrance of bleeding, elevated temp, additional swelling, absence of a thrill)
when should conductivity and ph of dialysate be checked? CORRECT>>- prior to initiation of every tx, before hanson connectors are attached to dialyzer how is weight gain, available weight, target weight and ml/kg/hr calculated? CORRECT>>- Today weight-EDW=ADW ADW+0.5kg=UF goal UF Goal/EDW/Time= ml/kg/hr (this value must be less than 13 to initiate tx
air embolism treatment CORRECT>>- C: clamp venous line (prevents additional air from getting to pt) O: Off with the blood pump (pressure will build in lines with venous clamp clamped)- also stands for oxygen L: Left side positioning (air rises so positioning pt on left helps prevent air from entering heart) T: Trendelenburg (prevents air from entering heart, brain, lungs vascular access-fistula advantages/disadvantages CORRECT>>- advantage: pt's own vessel, only one anastomosis required, longer life span, decreased rate of complications, collateral circulation develops disadvantage: takes 1-4 months o develop, isometric exercises may aid in development, lower blood flows necessary while fistula is immature (results in poor clearance), collateral circulation develops pt's with co-morbid conditions (diabetes, hypertension, poor circulation, obesity) make placement of av fistula more difficult vascular access- graft advantages/disadvantages CORRECT>>- advantage: larger surface area for cannulation, easy to cannulate, short healing time, variety shapes/configurations, easy to implant, constrct, and surgically repair disadvantage: increased rate of stenosis, increased infectin rates, increased bleed time at end of tx, requires replacement especially if cannulation sites are not rotated, no collateral circulation develops cvc acess- advantages/ disadvantages CORRECT>>- advantages: immediate use after verification of placement, no need for pt to acheive hemostasis at end of tx disadvantage: high potential for air embolism, prone to infection and clotting, last option and sometimes only options for patients, lower bfr (increased tx time to improve adequacy), long term use can lead to major vessel stenosis, reversing lines will cause increased reciruclation and decreased adequacy 4 things to teach pt to prevent access from clotting CORRECT>>- 1. avoid tight fitting clothing or jewelry on access arm
- avoid sleeping on access arm
- avoid lab draws or blood pressure checks in access arm
- avoid carrying heavy objects in access arm
- personal hygine and importance of keeping access clean to prevent infection what is emla cream CORRECT>>- Lidocaine 2.5% and Prilocaine 2.5%. anesthetic cram used to numb area for cannulation. is applied at home at least an hour before tx Needle safety devices must: CORRECT>>- be engaged while removing needle from access
what is the difference between spkkt/v and ekt/v and how is it determined? CORRECT>>- spkt/v: single pool is the amount of dialysis having been delivered upon completion of the hemodialysis treatment. single pool is urea reduction from one pool of fluid (the vascular space). minimum of 1.4 L is required, determination is n/a ekt/v: double pool is the measured amount of dialysis accounting for the volume of urea distribution in both intracellular and extreacellular compartments. it represents the amount of urea distribution of the entire body accounting for all body fluid compartments. minimum if 1.2 L is required. labs are drawn monthly to measure ekt/v. the ukm program in the computer information system is used to determine the adequacy results using data entered, which includes treatment parameters and lab work results. why is the extracorporeal circuit primed with normal saline? CORRECT>>- purge the system of any sterilant or particulate matter from the manufacturer and air that is in the system. priming at 150 ml/min ensures dialyzer fibers are thoroughly wetted and aids in clot prevention (adequate dialysis) how much saline should be infused through the e-beam dialyzer and the extracorporeal circuit? CORRECT>>- approx 300 to prime dialyzer and circuit. fresh fill is 50 through arterial and 250 thorugh venous at what point during the priming process should hanson connectors be connected to the dialyzer? CORRECT>>- after priming, testing, and conductivity/ph test has been completed at what blood pump speed is the extracorporeal circuit primed? CORRECT>>- 150 what position should the dialyzer be in during circulation? CORRECT>>- venous end up how is e-beam dialyzer circulated? CORRECT>>- after priming and testing, connect and unclamp transducers, attach hanson connectors. turn bfr to 300 - 400 and dfr to
- tap venous end of dialyzer and pinch/release arterial line to remove all air what should i do after the air is removed during circulation? CORRECT>>- dialysate flow to 300 and brf at 300. machine is ready for pt. what is kecn and what range should it run CORRECT>>- clearance effective by conductivity of sodium. refers to clearance of sodium as measured by the conductivity changes during olc test. kecn should be less than bfr (impossible to remove wastes faster than the blood pump speed) and should be 200-300. what is the mean kecn CORRECT>>- average of all test performed during on line clearance and must be documented on the hemodialysis flow sheet and in computer system. how many kecn tests can be programmmed into olc? CORRECT>>- 3 - 6 tests, if tx is 3 - 4 hours 6 tests should be programmed
what does a steady decline in kecn test results signify? CORRECT>>- dialyzer clearance of waste from blood is decreasing, could be from inadequate heparinization, clotted dialyzer fibers. decrease in kecn can also be from obstructed arterial flow when is the machine temperature checked? CORRECT>>- when conductivity and temp are stable, document before tx is started what items are considered when administering medications to renal failure pts? CORRECT>>- kidneys are major route of excretion for drugs/ metabolites. caution must be used bc loss of renal function will decrease elimination of medications and could potentially cause toxicity, increased potency/duration of drug's effects, and increased frequency of side effects. can medications be pre-drawn? CORRECT>>- up to 4 hours prior to administration. must be labeled and kept under preparer's control or locked in designated medication storage area or refrigerated if necessary what if the patient doesn't come for treatment and the medications were pre drawn? CORRECT>>- could be relabeled and administered to another pt if it has not left the medication preparation area and the dose matches physician's order what lab is evaluated to determine adequacy of tx? CORRECT>>- blood urea nitrogen levels are evaluated to determine adequacy of tx what is the procedure for drawing post tx lab work (post bun)? CORRECT>>- 1. turn off UF (turn off dialysate flow and bfr is decreased to 100 for 15 seconds)
- stop blood pump
- clamp arterial and venous needle lines
- clean arterial port with alcohol wipe and collect sample
- invert sample 5 - 10 times
- turn dialysate flow on
- open clamps on needle lines
- return blood per termination procedure what complications require rn involvement and assessment? CORRECT>>- all findings outside normal and expected pt evaluation findings are reported to rn. rn is responsible for assessment, nursing intervention, and implementing emergency responses. what is bradycardia and whom is it reported? CORRECT>>- pulse less than 60 bpm. is concidered severe when 50 bpm or less. all episodes of bradycardia must be reported to rn why do some pts become hypoglycemic and what are the signs and symptoms? CORRECT>>- some glucose is removed during tx and pt may experience sx of hypoglycemia (faitness, double vision, irritability, hunger) what can lead to hemolysis? CORRECT>>- hypotonic solution, chlorine/chloramine breakthrough, high temp, kinks in bloodlines
Parathyroid senses low bp (from no renin) so excretes PTH to signal calcium excretion from bone marrow what is estimated dry weight? CORRECT>>- weight of the pt if all excess fluid is removed and bp is normotensive. the leading cause of death in esrd pt is related to cardiac function and fluid. excess and removal plays a vital role in cardiac function what is the difference between available weight and target weight? CORRECT>>- aw is available fluid weight that needs to be removed from pt during today's tx. aw is calculated by substracting edw from pretreatment weight target weight is the weight loss plan including aw, priming/rinseback, and any fluid pt will receive during treatment to ensure pt safety and prevent hemolysis or crenation, the final dialysate is checked to verify that the dialysate is compatible with the human biochemistry. the following components are checked CORRECT>>- ph, conductivity, temp what are the details about checking ph and conductivity? CORRECT>>- when: prior to all tx initiated or anytime concentrates are changed. should be completed before the hanson connectors are attached to the dialyzer. why: to validate machine settings are correct expected result: ph range 6.9-7.6, conductivity range +-0. what are the details about checking residual bleach post machine disinfection? CORRECT>>- when: prior to each shift of pt treatments why: to ensure no bleach remains in fluid pathway how: using residual test strips according to manufacturer's instructions for use what are the details about checking total chlorine routine testing? CORRECT>>- when: prior to each shift of pt treatments and not to exceed 4 hours where: post gac tank # why: to ensure chlorine and chloramine levels are within aami standards how: sample collected after water system has run for 15 min. rpc test strip swished in sample for 60 seconds, strips conpared to color chart on container. results less than .10 is safe for treatment, if higher, breakthrough testing initiated. what are the details about checking total chlorine breakthrough CORRECT>>- when: every 2 hours when total chlorine levels equal 0.10 or higher post gac tank #1 where: post gac # why: ensure total chlorine levels remain less than 0. if result less than 0.10 it is safe to continue, if 0.10 or higher, immediately notify rn and sto treatments to avoid accidental pt exposure what are dialysis precautions? CORRECT>>- set of standard infection control practices that are used in all situations in the dialysis setting when caring for dialysis pts or performing related activities. dialysis precautions have been shown to reduce infectious disease transmission and are recommended by cdc
when are dialysis precautions applicable? CORRECT>>- anytime there is the potential or actual exposure to blood, body fluids with visible blood, amniotic, cerebrospinal, pericardial, pleural, synovial, and peritoneal fluids, body tissues, feces, nasal secretions, sputum, sweat, tears, urine, vomit, vaginal secretion, semen. what approach is taken for dialysis precautions? CORRECT>>- assume all patients are infectious, and all blood, body fluids, tissues, needles, sharps, used dialyzers, supplies and equipment are contaminated. why dialysis precautions? CORRECT>>- dialysis patients are immunocompromised
patients experiencing repeated invasive procedures - > dialysis is a high-risk area - frequent exposure to blood or body fluids - > patients and staff in close proximity - > bleach solution strength 1:100 CORRECT>>- general disinfection when blood is not visible or blood spills less than 10 mls bleach solution strength 1:10 CORRECT>>- cleaning blood spills greater than 10 mls, then followed by cleaning with 1:00 solution what items are placed in sharps container? CORRECT>>- broken glass, ampules, syringes with needles when are sharps containers replaced? CORRECT>>- close, lock, and replace sharps containers when 2/3rds to 3/4ths full. do not shake to condense contents. what is done with sharps containers in an emergency? CORRECT>>- remove all medical waste containers (sharps and biohaz) from treatment floor. lock lids and place in locked biohaz room. what precautions are taken when caring for mrsa/vre patients? CORRECT>>- dedicated gown, do not need isolation but should be seated in same areas (cohorting) with others who are also infected with the same bacteria. designate bp cuff, stethoscope, open wounds should be covered and wound dressings should never be opened or changed in dialysis treatment rooms. all environmental surfaces touched by mrsa/vre patients should be thoroughly cleansed with 1:100 bleach solutions list three blood borne pathogens that may be found in a dialysis unit CORRECT>>- hep b, hep c, hiv what is hepatitis, and how can the viral forms be spread? CORRECT>>- hepatitis: inflammation of the liver with a variety of causes, all are contagious hep a: contaminated food, oral, and fecal route hep b: blood or bodily fluids route, virus can live on surfaces at least 7 days, patients require isolation if hbsag is reactive or positive hep c: blood or bodily fluids route, some medications will cure depending on genotype of virus hep d: blood or bodily fluids route, a ribonucleic acid virus that require hbv for replication (uncommon in dialysis patients)
results of our efforts. assess success of facility processes in meeting clinical and operational goals and objectives by reviewing cqs measurement tool. qai and cqs process drives empowerment to achieve: quality outcomes, regulatory compliance, day to day operations when is cardiac arrest suspected with a patient experiencing chest pain? CORRECT>>- chest pain, unrelieved by oxygen indicates cardiac arrest list some incidents that would require an adverse event report? CORRECT>>- abusive/violent behavior, acute and severe psychotic event, air embolus, blood loss
100 ml, cardiac arrest, congestive heart failure/symptomatic fluid overload, inability to cannulate, contaminated needle stick by pt only, fall resulting in inury, incorrect dialyzer or dialysate used resulting in pt injury, medication errors or omissions what is a near miss? CORRECT>>- a potential hazard or incident that did not result in patient harm yet had the possibility of doing so why is water treated? CORRECT>>- patients are exposed to large amounts of water during dialysis, therefor the water must be treated to ensure it is free from harmful contaminates. chlorine and chloramines are added to city water to reduce/eliminated bacteria AAMI CORRECT>>- Association for the Advancement of Medical Instrumentation. develops voluntary standards for various aspects of dialysis treatment, including maximum levels of water contaminates water contaminants CORRECT>>- aluminum, chloramine, copper, zinc bacteria and endotoxins CORRECT>>- bacteria can cause sepsis, bacteria and viruses can cross dialyzer membrane. endotoxin is released from the cell wall of dead bacteria. characteristics include rapid growth and production of endotoxins or biofilm hemolysis due to water CORRECT>>- exposue to chlorine and chloramine, total chlorine can cross dialyzer membrane causing hemolysis. pt symptoms include low bp, chest pain, dyspnea, cherry soda red/translucent blood pyrogenic reaction CORRECT>>- exposure to bacteria and endotoxins symptoms include fever, chills, nausea/vomiting, hypotension cluster of patient symptoms CORRECT>>- patients experiencing similar symptoms, always suspect a water emergency and take appropriate action backflow preventer: CORRECT>>- first piece of equipment that the water goes through in dialysis facility, prevents water from flowing back into the city water supply water booster pump: CORRECT>>- increases incoming city water pressure air (expansion/bladder) tank CORRECT>>- assists in maintaining minimum water pressure
chemical feed pumps CORRECT>>- adjusts the ph of water sediment/multimedia filter CORRECT>>- removes larger particles from the incoming water (10 microns or larger) carbon tank CORRECT>>- removes chlorine, chloramines, and other organic material through adsorption (adhesion of molecules/ions from liquid gas or dissolved solid onto a surface) EBCT CORRECT>>- empty bed contact time, length of time that the water is exposed to carbon AAMI requires 10 min, FKC requires 12 min water softener CORRECT>>- removes calcium and magnesium through process of ion exchange RO product water exits the RO and meets AAMI standards for water to be used for dialysis CORRECT>>- performance measured by % rejection, membranes must be replaced at 80% rejection. membrane must be replaced bc ability to remove dissolved solids is too low. TDS (total disolved solids) is measured and documented daily. water exceeding he TDS alarm limit is diverted to the drain ultrafilters CORRECT>>- remove bacteria and endotoxin and are located after the RO machine "final step" UV Light CORRECT>>- form of invisible radiation, kills bacteria Product water divert valvue CORRECT>>- sends water to drain when it exceeds the tms alarm limit deionization tanks CORRECT>>- method of water treatment used during RO failure and are part of the "alternate water supply plan" total chlorine testing CORRECT>>- 1. RO machine runs 15 minutes before performing any total chlorine testing
- must be performed and documented by 2 qualified staff members (one pct and one nurse)
- 100 ml is the correct amount of water to collect (must rinse sample container 3 times)
- RPC ultra low total chlorine test strips are immersed in sample for 60 seconds
- total chlorine tested prior to initiation of tx and at least every 4 hours
- rpc ultra low chlorine test strips are used to test for total chlorine in water after carbon tank and post ro
- safe range is 0.00-0.09 ppm
- documentation in tms
- first total chlorine sample should be taken from post carbon tank (worker), second sample taken post RO
