Module 1 Flashcards
Kidney Theory; Infection Control; Hemodialysis Process, System & Devices
What are the four transport mechanisms that play a role in hemodialysis?
Ultrafiltration, Convection, Diffusion, and Osmosis
What is Ultrafiltration?
Fluid is pushed through a semipermeable membrane
What is Convection?
Solutes or particles pulled across a membrane by water movement
also known as Solute Drag
What is Diffusion?
Solutes moving from an area of higher concentration to an area of lower concentration.
What is Osmosis?
The movement of water across a membrane to equalize solute concentrations, from an area of low concentration to an area of high concentration.
What are the kidney’s excretory functions?
To normalize electrolytes, remove wastes, and provide fluid & acid base balance.
Allows body to maintain homeostasis.
How do we replace normal excretory kidney functions?
By utilizing a dialyzer or “Artificial Kidney”
What is the function of bicarbonate in the dialysate solution?
Bicarbonate acts a buffer to the Acid
What is the function of bicarbonate when it diffuses into the patient’s blood?
Prevents patient’s blood pH from dropping to dangerous levels during treatment.
What percent of dialysate is purified water?
90%
What is the formula for Venous Pressure?
Venous Pressure (VP) = Filter Pressure + (Return Pressure/2)
What does TMP stand for?
Transmembrane Pressure
What is the Formula for TMP?
TMP= Venous Pressure (VP) - Dialysate Pressure
What does the Acid Concentrate contain?
Sodium (Na+), Magnesium (Mg+), Acetate(C2H3O2-), Chloride (Cl-), Dextrose (C6H12O6)
What is the function of the acid concentrate?
Adds electrolytes in precise amounts.
Is necessary to prevent calcium and magnesium from precipitating out of the bath.
(Precipitation: solute particles find each other and form a solid together)
What does Target Weight mean?
Post-dialysis weight that patient can safely & reasonably achieve after dialysis.
Decided on by Nurse & Patient for each treatment as to the amount of fluid to be removed
What does hemodialysis do?
Helps to normalize body pH through diffusion of bicarbonate from the dialysate into the blood.
What is eliminated through the dialyzer fibers by diffusion?
Blood Urea Nitrogen (BUN) & Creatine
What is BUN?
Blood Urea Nitrogen
Waste products from protein metabolism
What is Creatine?
Waste products from muscle metabolism
What are signs and symptoms of Hyperkalemia?
Potassium (K+) electrolytes are too high
>5.5mEq
Weakness, slow heartbeat, cardiac arrest
What are signs and symptoms of Hypokalemia?
Potassium (K+) electrolytes are too low
<3.5mEq
Cardiac Arrhythmias
What is the normal blood pH range?
7.35-7.45
What are the kidney’s endocrine functions?
Renin secretion, Erythropoietin secretion, Vitamin D activation
What is Vitamin D activation?
Decreased serum calcium levels –> kidneys convert Vitamin D3 into active form Calcitriol –> Calcitriol stimulates absorption of dietary calcium & phosphorus from the gut (small intestine)
How do we replace normal endocrine kidney functions?
Provide Medications
What is the lifespan of a red blood cell?
120 days
What is the Criteria for Chronic Kidney Disease (CKD)?
Abnormalities of kidney structure or function > 3months, w/ health complications
Duration >3 months based on Doctor evaluation & documentation (from Acute to CKD)
How much of normal kidney function is replaced by hemodialysis?
15%
3-4 hours, 3x a week
What can happen to patients who do not get enough dialysis?
They can develop uremic symptoms
What is Uremia and how does it affect the body?
Buildup of wastes in the blood due to kidney failure and affects all body systems
What is Uremic Syndrome?
signs and symptoms that result from toxic effects of elevated Nitrogenous and other wastes in the blood.
Symptoms progress slowly and affect all body systems
Symptoms & Signs: Edema, itching, flu like symptoms (nausea, muscle aches ,vomiting, poor appetite)
Other signs or symptoms: Hypertension, anorexia, restlessness, dyspnea, shortness of breath, fatigue, weakness, Xerosis, pseudoporphyria
What is Pseudoporphyria?
a rare skin condition that causes blistering and skin fragility in areas of the body exposed to sunlight
What are the most common causes of CKD in the USA?
Diabetes
Hypertension
Polycystic Kidney Disease
Outline the treatment goals for a patient with CKD
Slowing the progression of CKD
Managing comorbidities and complications
Controlling symptoms
Minimizing the effects of CKD on patients’ lifestyles
Kidney replacement therapy modality education
Encouraging patients to actively participate in their healthcare
What are Pre-Renal Causes of CKD
Prolonged shock, very low blood pressure, injury w/ significant blood loss, Massive internal bleeding, narrowing of arterial vessel.
What are Intrarenal Causes of CKD
Diabetes mellitus, hypertension, drugs/medication, Polycystic kidney disease (hereditary), LUPUS, Sickle cell anemia, Glomerulonephritis
What are Post-Renal Causes of CKD
Kidney stones, tumor in bladder, stenosis, enlarged prostate
Irreversible & Permanent
What are the stages of CKD
Stage 1: GFR = 90+
Stage 2: GFR = 60-89
Stage 3A: GFR = 34-59
Stage 3B: GFR = 30-44
Stage 4: GFR = 15-29 (Begin planning for Kidney Replacement Therapy- In Center Hemodialysis(ICHD) or Home Hemodialysis (HHD))
Stage 5: GFR <15
What is GFR
Glomerular Filtration Rate (mL/min)
Estimates how much blood passes through the glomeruli
Why is it important to know what caused your patient’s CKD?
So the nurse and PCT can inquire about possible problems during data collection and assessment
What are signs & symptoms of fluid imbalance?
Hypertension
Edema
Shortness of breath
Why is sodium balance important?
Leads to volume expansion, increased cardiac output, increased peripheral vascular resistance, and increased blood pressure
What would you advise for a patient who complains of this CKD symptom:
Dry, Itchy Skin
Use hyper-fatted soaps and lotion
What would you advise for a patient who complains of this CKD symptom:
Peripheral Neuropathy (Nerve pain in the extremities)
Monitor patient for changes in motor function, decreased strength in legs, complaints of restless legs, burning feet.
Advise patient to not walk barefoot, and have good foot care practices.
What would you advise for a patient who complains of this CKD symptom:
GI Problems (nausea/vomiting)
Inform RN & Physician of any bleeding problems/constipation/diarrhea/ER visits, take medications as ordered (stool softeners/Imodium)
What would you advise for a patient who complains of this CKD symptom:
Psychological Problems (Anxiety/depression)
Verbalize struggles to IDT (Core Team) especially the social worker
What is a consequence of prolonged fluid overload and hypertension?
Left Ventricular Hypertrophy (LVH)
What is pericarditis?
Inflammation of the membrane (Pericardial sac) around the heart
What are Pericarditis Symptoms?
Constant pain in center of chest
Fever
Low Blood Pressure (Hypotension)
Irregular Heartbeat (Arrhythmia)
Pericardial Friction Rub
What is Pericardial Friction Rub?
A typical heart sound that can be heard & sometimes described as a “scratching” sound
What is the treatment for pericarditis?
Decrease or stop heparin
More frequent dialysis
Getting enough fluids
Anti-Inflammatory Drugs
Antibiotics
Possible surgery to relieve pressure in the sac surrounding the heart
What is Uremic Pericarditis?
A rare and potentially life-threatening complication of end-stage renal disease
More likely to occur in patients w/ severe azotemia (abnormally high levels of nitrogen-containing compounds in the blood due to kidneys not filtering blood properly or enough), or elevated BUN levels >60mg/dL
What is Dialysis-Associated Pericarditis?
A complication that can occur in patients on chronic hemodialysis or intermittent HD who have been stabilized on renal replacement therapy
Thought to be caused by inadequate dialysis, which can lead to fluid overload
Can be due to low flow rates, dialysis noncompliance, or access complications
Symptoms usually appear after 8 weeks of renal replacement therapy
What is a common cause of hypertension in dialysis patients?
Fluid Overload
Left Ventricular Hypertrophy leads to what?
Ischemic Heart Disease
Arrhythmia
Myocardial Infarction
Sudden Death
What is Left Ventricular Hypertrophy (LVH)
The enlargement & thickening (hypertrophy) of the walls of the heart’s main pumping chamber (left ventricle)
What can cause LVH?
High Blood Pressure(Hypertension)
A heart condition
Chronic Fluid Overload
What are negatives of LVH?
Prevents chamber from:
-filling completely
-pumping effectively
Harder for left ventricle to push needed amounts of blood out of ventricle and into aorta
May eventually fail to pump with force needed
Hypertrophy compresses coronary arteries restricting blood supply
Heart Failure: “Failure” of the heart to effectively pump blood throughout the body (Becomes common)
What is Intradialytic Hypotension?
A common and serious complication that occurs when a patient’s blood pressure drop during hemodialysis (Most Frequent = 10%-20%)
Defined as a systolic blood pressure (SBP) of <90mm/Hg, or a decline of more than 30mm/Hg from pre-dialysis levels.
A decrease in mean arterial pressure (MAP) of more than 20%, or rapid symptomatic decline in SBP of more than 30mm/Hg
How likely are patient’s with LVH like to become hypotensive?
10x more
What is Ischemic Heart Disease (IHD)?
A condition where the heart doesn’t receive enough blood & oxygen
Usually caused by a buildup of plaque (atherosclerosis), in the coronary arteries that supply blood
The plaque can narrow the arteries, or even block them completely leading to heart muscle cell death. (Heart Attack or Myocardial Infarction)
Also known as Coronary Heart Disease
What are complications of LVH
Irregular Heart Beats (dysrhythmia)
Heart Attack (Myocardial Infarction)
Sudden, unexpected loss of heart function/cardiac arrest (Arrhythmia)
Sudden Death
What are LVH Symptoms?
Shortness of Breath
Fatigue
Chest pain, often after exercising
Sensations of rapid, fluttering, or pounding heartbeats (palpitations)
Dizziness or fainting
What is the treatment goal for LVH?
Lifestyle Changes:
- Diet
- Exercising
- Smoking Cessation
Take BP medication as prescribed to prevent hypertension
Take diuretic medication as prescribed to prevent fluid overload
Surgery to repair or replace damaged valve (if necessary)
What is the Primary Cause for a patient’s anemia?
Lack of Erythropoietin (EPO)
What is the secondary causes for a patient’s anemia?
Inadequate iron stores
Inadequate dialysis
Malnutrition
Blood loss during treatment
What can you do to avoid contributing to lower hemoglobin and blood loss in dialysis patients?
Verify correct Erythropoietin Stimulating Agent (ESA) dose is administered
Rinse back until venous line is pink tinged
Avoid repeat lab draws
What are the four key elements contributing to CKD - Mineral Bone Disorder (MBD)?
Calcium
Phosphorus
PTH (Parathyroid Hormone)
Vitamin D (Calcitriol)
What are symptoms of CKD-MBD in addition to bone disease?
Soft tissue calcification
Itching
Muscle Weakness
Pathological Fractures
Tendon Ruptures
Compression of vertebrae
Atherosclerosis
Heart Disease
What is your role in CKD-MBD Management?
Report symptoms
Urge Patients to take medications (home & incenter)
Repot problems related to nonadherence
Define the term AKI
Term incorporates a wide spectrum of kidney issues
Includes acute kidney failure as well as less catastrophic kidney function changes
May dialyze in an out-patient facility until kidney function recovers
What are 3 examples of pre-renal causes of AKI
Obstruction
Volume Depletion
Impaired Cardiac Function- Decreased Cardiac Output
What are 3 examples of Intra-renal causes of AKI
Ischemic ATN
Sepsis
Acute Interstitial Nephritis
Septic Shock
Anaphylaxis
Drugs
Goodpasture Syndrome
Acute Glomerulonephritis
Trauma
Open Heart Surgery
What are 3 examples of Post-Renal causes of AKI
Obstruction
Bladder Rupture
Pregnancy
What is the difference between AKI and CKD?
Eliminating the cause of the AKI can often lead to the return of kidney function
You cannot eliminate the cause of CKD which is HTN, Diabetes, Genetic Disorders (PKD)
Outline the treatment goals for a patient with AKI dialyzing in the out-patient facility.
How do you help in restoring kidney function?
Find the cause of the AKI
Outline the treatment goals for a patient with AKI dialyzing in the out-patient facility.
What do you need to consider in regards to their vascular access?
Patients will typically have a dialysis catheter, be careful to avoid catheter related infections
Outline the treatment goals for a patient with AKI dialyzing in the out-patient facility.
How do you protect kidneys from further injury?
Avoid substances to the kidney which may be toxic(radiographic contrast, amphotericin b, low dose aspiring, NSAIDS)
What is important when monitoring weight and BP?
Keep a little extra fluid on the patient so it is available to the kidneys when they start filtering/ultra-filtering on their own
AKI patients are at increased risk for which complications?
Hypovolemia and hypotension
What is the difference between OSHA and CMS infection control requirements?
OSHA: Requires employers to provide workers with a safe workplace
CMS: Concerned with patient care and patient safety
What are V-tags and why are they important
They state specific regulations to be met within a condition such as infection control, providing interpretive guidance for each regulation and citing deficiencies by tag #
Explain the acceptable hand hygiene technique when caring for a patient with active Clostridioides difficile infection (C diff)?
Handwashing with soap and water per policy is the only acceptable hand hygiene
What is the most common infectious complication in hemodialysis patients?
Bacterial vascular access infections are the most frequent infectious complication
What organism causes the most common infections in hemodialysis patients
Methicillin-resistant Staphylococcus Aureus (MRSA) - Must pay attention to infection control
Proper hand hygiene, cleaning and disinfecting procedures to prevent the spread of infection (viable on surfaces for days)
What is the importance of wearing gloves?
Reduces the risk of hand contamination and prevents the transfer of organisms already on hands to a patient
Why do you need to perform hand hygiene before and after wearing gloves?
Gloves are not impervious and have microscopic pores
Who can use clean sinks for hand washing
Teammates and Patients
Is a cleaned dialysis machine considered a ‘clean’ area
NO
How can you tell when an area or sink is clean or dirty in your facility
It is clearly labeled with a ‘clean’ or ‘dirty’ sign
What is “strikethrough” of an external pressure transducer and why is it of concern
It is when fluid could have entered the machine and contaminated the internal pressure transducer protector providing a reservoir for microorganisms and causing subsequent patient blood infections
When should sharps and biohazard containers be removed from the treatment floor
When they are 3/4 full
Explain the HBV classification and state which test is performed monthly on HBV susceptible patients
HBsAg: Hepatitis B surface Antigen -(TESTED MONTHLY)
HBsAb (Anti-HBs): Hepatitis B Surface Antibody
HBcAb (Anti-HBc): Hepatitis B Core Antibody
How do surveyors verify teammates have completed infection control training and education?
Documentation of infection control training in the teammate’s file or transcript
Which patient care assignments are appropriate when caring for Hepatitis B Patients
Caring for HBsAg+ and Hep B immune patients at the same time
Caring for Hepatitis B susceptible patients and those in the process of receiving the vaccination at the same time
Caring for Hep B immune and susceptible patients at the same time
State the 3 strategies recommended to decrease the risk of infection when working with a CVC
Using facemasks when lumens or exit sit is exposed
Wearing clean gloves and avoid touching exposed surfaces
Minimizing catheter lumen or exit sites from being exposed
What is the most common transmission route for HAIs
Contact Transmission
What is the reason that dialysis patients are at increased risk for acquiring a HAI at the facility
Chronic Kidney Disease patients are immunosuppressed and more vulnerable to infection.
Infection is the second most common cause of death in this dialysis patients
What contributes to hemodialysis patients being placed at increased risk for acquiring a HAI at the facility
Kidney failure weakens the immune system making the patients more vulnerable
Dialysis patients often times have multiple comorbid conditions, which further weakens the immune system
The dialysis procedure itself requires prolongeed access to the patient’s blood, especially those involving CVC vascular accesses, making them more at risk
What is the correct procedure in regards to your hands when you have casual contact with a patient
Glove are not necessary for casual social contact, but hand hygiene is required after every direct contact with a patient and between patient contacts, even if the contact is casual
What is the most important intervention you can do to prevent HAIs
Performing Hang Hygiene
What is the total proportion of dialysate used at DaVita? (Mixture of specific proportions of acid, bicarbonate, and dialysis quality waters)
45x
What are the two most frequent physician prescribed potassium strengths of dialysate concentrate used at DaVita?
2.0 K+ and 3.0 K+
Which part of the kidney functions similarly to the dialyzer’s semi-permeable membrane to provide filtration and removal of fluids and toxins
Glomerulus
What are the two waste products removed by dialysis that we monitor with monthly labs?
Blood Urea Nitrogen (BUN)
Creatinine
How often are dialysis machine alarm tests performed
Before the initiation of each patient treatment
The manual conductivity value must be within what range of the Theoretical and Prescribed
+/- 0.4mS
What is the safe dialysate pH range
6.9-7.6
Why is it important for patient care teammates to know when the water treatment system disinfection was performed
Because the end-to-end disinfection process will also introduce the disinfectant solution to the dialysis delivery systems through their water inlet lines
Why are the dialyzer and blood lines not used for a dialysis treatment once recirculating for longer than 2 hours?
Because of the potential for bacterial growth
What is the correct procedure for residual bleach testing after the chemical disinfection of loops and equipment fluid pathways?
Residual bleach testing should be performed after bleach disinfection and prior to equipment use
