Evaluating & Monitoring your Patient SG Flashcards
Pre-treatment Evaluation of your Patient
- What is pre-dialysis evaluation?
- review of the patients health before treatment begins
2. compares current health status to previous evaluations
Pre-treatment Evaluation of your Patient
- Why is the pre-evaluation of your dialysis patient needed?
- to determine if the patient is stable to receive treatment
- has there been any changes in health status
- provide baseline data to plan for a safe treatment
describe universal precautions:
the steps we take with all patient contact to decrease the risk of spreading infection to protect our patients and ourselves
What are the 3 C’s of patient evaluation?
Condition
complaints
changes
The condition of a patient is based on general findings of each of the following?
- Ambulation
- Mental status and mood
- Skin
- vital signs
ambulation:
What should you look for?
gait changes, use of any assistive devices, ROM, and energy level
Mental Status and Mood:
What should you look for?
aaox3
any changes in usual mood
Skin:
What should you look for?
color
integrity
temperature
edema
Vital Signs
What should you look for?
weight
BP
HR
Respirations
temperature
What is an EDW?
a patients weight with excess fluid removed
When is the Rn required to assess the patients pre-treatment weight?
if the pretreatment weight is 4kg above the EDW
What does the blood pressure measure?
measurement of the pressure or force of blood against the walls of the arteries
When do you report a blood pressure to the Rn
SBP <100 or > 200 DBP > 100
when do you report a HR to the RN?
new onset of HR less than 60 or greater than 100 or irregular
When do you report a respiratory rate to the RN?
greater than 24
true or false
does a dialysis patient maintain an average temperature
false
When do you report a temperature a temperature to the RN
less than 96
or = 100
name some important complaints that you need to report to the RN
- dizziness
- chest pain
- SOB
- any new complaints
- a visit to the ED or hospital stay
- weakness
- numbness and tingling
- fever and chills
- depression
- pain
What changes do you report to the RN
new meds or visits to the ED or hospital stay
communication of ALL abnormal findings are required to ensure ______
patient safety
What are your state specific guidelines on when a patient needs a pre-dialysis assessment
Tennessee requires that all patients need an assessment
Name the ABC’s of a patient assessment
Access
breathing
cardiac
Access:
describe what to look for:
bruises
redness
drainage
swelling
bruit
thrill
pain
bleeding
Breathing:
describe what to look for?
rate
rhythm
quality
SOB
breath sounds
cardiac
describe what to look for?
skin color and turgor
heart sounds
pulse rate
rhythm and quality
edema
pain
SOB
Why do patients experience crackles (rales) breath sounds?
indicates fluid or congestion in the lungs
Name some reasons for an abnormal heart rate?
can indicate chemical imbalances or adverse effects from medications
assessment of _____ is essential when you are evaluating a patient’s cardiovascular system?
EDEMA
name some places that fluid may get trapped
abdomen lungs feet legs hands face
_____ refers to the identification made when you press your finger or thumb into the tissue of edema and it ranges from 1-4
PITTING
If you have a red light such as a complaint, __ ____, start the treatment until _______.
DO NOT start the treatment until THE RN HAS DONE A FULL ASSESSMENT ON THE PATIENT
Name what verifies the correct patients dialysis prescription?
- patients identity
- prescribed dialyzer
- prescribed dialysate
- prescribed needle size
- special attention orders
- SVS or UF profiling
- prescribed heparin dose
- OLC volume / tests entered
- prescribed dialysate rate
- prescribed base sodium
- prescribed bicarbonate
Name the important information programmed into the machine.
- prescribed treatment time
- UF goal entered correctly
- prescribed BFR
- prescribed DFR
- OLC volume
- Na modeling or UF profile
name the final dialysis machine safety checks
- dialysate temperature
- dialysate pH and conductivity
- NS double clamped
- alarm and pressure holding tests passed
- final check of blood circuit
______ is our priority and the major reason we monitor our patients
Patient safety
as fluid shifts during dialysis, changes in ____ and _______ can occur.
Blood Pressure
Fluid and Electrolyte balance
Who is responsible for monitoring patients?
everyone
The PCT must take _______ action if he or she identifies a potential problem
Immediate
The RN must respond to _______ or PCT notifications and assess the patients.
complaints
Why does a patient’s face and vascular access need to be visible at all times?
- it is a CMS requirement
- to identify any changes in patient awareness
- a covered access can result in major blood loss
monitoring red flags to report to the RN immediately would be:
- severe hypertension greater than 200
- severe hypotension less than 80
- new onset of pulse less than 60 or greater than 100
- irregular heart rate
- temp less than 96 and =100
and the RN’s response should be to assess the pt, provide intervention, call the DR
it is important to monitor the vascular access by observing if the needle site is _____, ensure that the needles and lines are _____ and that the _______ device is in place for a CVC.
bleeding
secure
hemoclip
name 4 non-verbal behaviors that may indicate a change in the patients status or discomfort:
- restless
- grimacing
- excessive yawning
- is patient alert, drowsy, sleepy
Name 5 changes you should educate your patient to report immediately
- discomfort at needle sites
- muscle cramps
- headache dizzy blurred vision
- nausea vomiting
- fever chills chest pain sob
name 4 machine readings we verify at every safety check
BFR
DFR
AP
VP
describe what the arterial pressure reading reflect:
refers to the pressure in the system from the patients vascular access to the blood pump
potential complications of high arterial pressure is _____ _____ and ______.
inadequate dialysis
hemolysis
name 5 reasons for high arterial pressure
- a kink in the arterial lines
- poor cardiac status
- blood pump speed too much for blood viscosity
- high BFR though a small needle gauge
- blood pump speed too much for vascular access
low arterial pressure could indicate a line ________ , air , decreased blood pump speed or a wet ______.
separation
transducer
describe what the venous pressure reading reflects:
the pressure in the circuit after the dialyzer and before it re-enters the patient
name 5 causes for low venous pressure
- blood line separation
- needle dislodgment
- decreased BFR
- clotting before the monitoring site
- wet transducer
high venous pressure can be caused by an occlusion in the lines between ________ and _______ or an _______ of the venous needle, poor CVC function or clotting in the access or ______.
monitoring site
venous needle
infiltrate
dialyzer
_________ is one of the most important functions of the dialysis treatment
fluid removal
fluid removal can also be monitored by using a _____ ______ or CLM
critline monitor
describe the 3 profiles that CLM provides:
Profile A:
flat or positive slope indicating UF and plasma refilling were equivalent during treatment . An increase in UFR may be appropriate.
describe the 3 profiles that CLM provides:
Profile B:
is a gradual slope indicating the best compromise between a high UFR and prevention of symptoms during treatment
describe the 3 profiles that CLM provides:
Profile C:
is a steep slope indicating a rapid decrease in blood volume and the patient is more likely to experience complications and intervention is required.
The adequacy management program (AMP) ensures our patients receive _____ dialysis every treatment
adequate
Kt/V represents a formula used to calculate adequacy by
K= ____
t= _____
V= _____
k= clearance t= time v= volume
The FMC target for hemodialysis
single pool/ spKt/V is _____.
1.4
Describe the AMP lights meaning:
Red:
the machine is in alarm mode
Describe the AMP lights meaning:
yellow:
means take action, the treatment will not meet our goal of 1.4 spKt/V
Describe the AMP lights meaning:
Green:
means the patient will meet our goal of 1.4 spKt/V
The extracorporeal circuit (ECC) circulates blood from _______ to the ______ back to _______.
the patients vascular access
to the dialyzer
back to the patient via the vascular access
monitoring the circuit includes:
- the entire circuit is visible
- lines allow the pts position to change
- all connections are correct and secure
- lines are secure in machine guides
- venous line in venous clamp
- chambers are filled adequately
- NS is double clamped and contains 300ml
- hansens are correctly connected to the dialyzer
- transducers are dry and unclamped
- heparin is infusing at prescribed rate
safety checks are done which include vital signs, vascular access checks, and machine checks must be done every ____ minutes unless the patient becomes unstable, then it increases to every ____ minutes until the patient becomes stable.
30 minutes
5 minutes
Name the safety check information that is documented in chairside:
- vas access is secure, visible no bleeding or infiltrates.
- BP and pulse
- BFR and DFR
- AP/ VP
- UF rate and UF removed
- rate of heparin infusion
7, most recent KECN and AMP light status
We also document the _______ to dialysis and note if there is a change in the condition or response
patients response
record your ______ to alarms, changes in vital signs, changes in treatment parameters, and machine adjustments.
interventions
Effective documentation should be:
- objective
- legible
- specific
- unaltered,
- consistent
- chronological
name who is responsible to document in the patients medical record
- nephrologist
- RN
- LPN
- PCT/CCHT
- RD
- SW
name 3 locations were we provide documentation:
- chairside
- eCube
- paper chart
Why is accurate documentation important?
communication evidence of care rendered and patients response, the chart is a legal document
