Module 2 Flashcards
Documentation, PCT Data Collection & Nurse Assessment, Fluid Management, Vascular Access, Laboratory, Hemodialysis Treatment
What are the key concepts related to “Reasonable & Prudent” Care?
The Standard of Care is care which a reasonable and prudent nephrology nurse would give under the same or similar circumstances
Actions a reasonable and prudent nephrology nurse would do, as well as actions the nurse would avoid doing
The skills and knowledge expected of a nephrology nurse is key to the specialty of nephrology nursing
Who established the Standards of Care for Nephrology Nursing and for what purpose?
American Nephrology Nurses Association (ANNA) establish the standards of care and scope of practice for Nephrology nursing
Standards of Care can serve as a basis for many areas including policy and procedures, protocols, educational offerings, regulatory systems, and more
What are three considerations when delegating nursing care activities?
Must be within the nurse’s scope of practice
Must be delegable by State Board of Nursing
Personnel must be adequately trained to perform activity
What role does DaVita’s P&P play?
Provides evidenced-based guidance
Meets CMS’ Conditions for Coverage (CfC)
Complies with state & federal law
What are the risks of performing activities your way?
Not providing safe and evidence-based care can lead to Civil Liability
What are the four reasons that we document in the medical record?
Proof that care was rendered
Provides data continuity
Communication Tool
Permanent Legal Record
List 6 occurrences when to document
Change from baseline assessment
Change in patient’s condition
Procedure performed or treatment provided
Medication given and patient response
Patient teaching
Care plan review and interventions
What does SMART communication stand for?
S: Simple: Keep message clear and simple
M: Meaningful: Think about what and why you are sending the message
A: Actual: just report the facts
R: Read: Make sure you are sending the message you intend
T: Teach: Others about SMART communication
What are the possible consequences of not using SMART communication?
Exposes you and DaVita to liability
Reputational Injury
Jeopardizes the recipient
Potentially career threatening
How do you document late entries?
From Policy 3-02-02: Medical Record Preparation and Charting Guidance
Late Entries: If unable to chart immediately after rendering a service or at the time of an observation, the teammate is to make the appropriate entry as soon as possible
Electronic: If documenting within the electronic medical record, the notation will automatically contain your electronic signature, date and time
Paper Chart: The late entry must be signed by the person making the late entry, and timed and dated at the time it is entered
How do you document charting errors?
When documenting on paper, draw a single line through the entry, date/signature/teammate credentials, chart the correct information
If documenting in an electronic health record system, follow facility procedure for that system
What is the difference between data collection and assessment and who is responsible for which?
Assessment- Nurse
- Determining Depth of edema
- Heart rate, rhythm, quality of heart sounds
- Respiration rate, rhythm, effort being put into breathing, identifying unusual lung sounds
Data Collection- PCT
- Noting presence of edema
- Counting the patient’s heart rate
- Respiration rate, recognizing unusual breath sounds
- Machine parameters, safety checks
What is the role of the licensed nurse prior to treatment initiation?
Assess abnormal findings from data collection, determine appropriate interventions (based on physician orders) and contact physician if needed.
When is a pre-treatment assessment by the RN required
For CKD hemodialysis patient: Based on State Law (may be before treatment initiation or within an hour of treatment initiation) or if data collection has abnormal findings
For patients with AKI: a pre-treatment is always required.
What is the role of the PCT prior to treatment initiation?
Complete data collection and PCT must notify the RN if there are any abnormal findings prior to initiation and treatment
What are the appropriate times for documentation?
Pre-treatment safety checks: Prior to treatment initiation
Pre-treatment Patient data collection: Completed pre-treatment/assessment: prior to treatment initiation if required by state law or within the 1st hour of dialysis treatment
Observations during treatment: Document Assessment pre-treatment, continuous monitoring during treatment, as they occur
Post Treatment Data Collection/Assessment: Must be done after treatment is complete - some of the things need post treatment:
- Documentation of clearance of dialyzer after rinse back
- Blood Pressure
- Heart Rate
- Temperature
- Respiratory Rate
- Weight
What is the preferred location for taking a blood pressure?
Upper, non-vascular access arm
What BP reading error can be caused by an incorrect cuff size?
Cuff too small: reading may be higher than actual BP
Cuff too large: reading may be lower than actual BP
What is a normal pre-treatment blood pressure?
Systolic: =/< 180mm/Hg or =/> 90mm/Hg
Diastolic: <100mg/Hg or >50mm/Hg
What is the normal heart rate range?
60-100 BPM
What is the normal respiratory range?
12-20 breaths
What is a normal temperature?
<100F or 37.8C
or
<2F(1C) change of Baseline (pre-treatment temperature reading)
The 3 words DaVita uses in order to easily recall the pre-treatment AVF/AVG access evaluation are:
Look
Listen
Feel
When is post-treatment assessment by the licensed nurse required?
If required by state law
If there were abnormal findings
What are the 6 “W”s to be used when completing a REM?
What
When
Where
Why
Witness
Who
What are the 3 things you should not include in a REM?
Personal Opinions
Speculation or Theories
Vendettas- Remember include only the facts!!!
Target weight:
Determined by physician order
TW is the physician prescribed weight post-dialysis that the patient can safely and reasonably achieve.TW is modified by the physician based on patient’s tolerance, ongoing signs of fluid overload, and changes in fluid status
Must be adjusted in a timely manner so that the physician’s most recent order is taken into account for each treatment. You may not adjust the TW retroactively.
Interdialytic Weight Gain (IDWG) Calculation:
Pre-weight - Last Post Weight
UF GOAL Calculation:
Pre-Weight
- Target Weight
+ Normal Saline Prime & Rinseback
+ Oral Intake, infusions
= UF GOAL
UFR (Ultrafiltration Rate) Calculation:
UF Goal/ Tx Hours = UFR
The maximum UFR should not exceed (unless ordered by the physician)?
13 mL/kg/hr
What are the four consequences of sodium loading during dialysis?
Increased thirst
Large fluid gains
More hypotension
Ischemic events during the hemodialysis treatment
State 3 ways we can contribute to sodium loading during dialysis
Giving patient broth
Administering Normal saline, hypertonic saline
Increased sodium in dialysate (high setting in machine or sodium modeling)
What are the consequences if a patient is consistently fluid overloaded (hypervolemia)
LVH
Increased Central Venous Pressure (CVP)
Hypertension
Increased mortality
Pulmonary edema
Increased hospitalization rate
State 3 ways we can contribute to sodium loading during dialysis
Giving Patient broth
Administering Normal Saline
Increased sodium in dialysate (high setting in machine or sodium modeling)
What are the consequences if a patient is consistently fluid overload (hypervolemia)?
LVH
Increased Central Venous Pressure (CVP)
Hypertension
Increased Mortality
Pulmonary Edema
Increased Hospitalization rate
What are the consequences and risks of hypovolemia/hypotension during the treatment?
Attempting to remove large amounts of fluid can lead to hypovolemia during the treatment which increases mortality, ischemia, and damage to vital organs (organ stunning) including the loss of residual kidney function.
What is the difference between an arteriovenous fistula (AVF) and an arteriovenous graft (AVG)?
AVF - Connection of the patient’s native artery to a native vein
AVG - Uses artificial or biological material & requires 2 connections
What is the point where an artery and a vein are connected to create an AVF?
Anastomosis
Describe the four AVF evaluations for maturation based on the KDOQI Rule of 6’s
> 600 ml flow through access (on Doppler)
< 0.6 cm in depth under the skin
0.6 cm diameter (width of pencil eraser
6-8 weeks post op maturation (some AVF will take longer - however notifying vascular surgeon is essential if access in not maturing)
(Rule of 6’s evaluation done by the surgeon)
Describe the teammate’s cannulation level based on Cannulator Competency Classifications
Beginner Cannulator
- less than 6 months of experience and less than 10 successful cannulations on established vascular accesses.
Proficient Cannulator
- Greater than 6 months experience and cannulation of greater than 10 successful cannulations
Expert Cannulator
- Experienced and skilled teammate. Has completed all the Expert Cannulation Program training, expert cannulation skills documented
What is the difference between a tunneled and a non-tunneled CVC?
Tunneled CVC has a cuff that the skin grows to for anchoring to the patient - it is kept in place longer. Sutures used at placement - but can be removed after site healed.
Non-tunneled CVC (often referred to as temporary) are held in place by sutures only - no cuff present
When can the hemodialysis treatment be initiated once the heparin loading dose is administered?
A minimum of 3-5 minutes after heparin administration
What is LOOK LISTEN FEEL
LOOK : Entire access from inflow back to the heart, observe for healing at sites, observe skin for cleanliness and intactness and drainage, new AVF for signs of maturation
LISTEN : For bruit- inflow stenosis (water hammer pulse) or outflow stenosis (whistling sound)
FEEL : Thrill (vibration) both AVF & AVG should be soft & compressible not hard and raised
Considerations for Newly mature arteriovenous fistula (AVF)
A newly mature fistula is defined as one that was recently created, has received its post-op exam by the surgeon/nephrologists and is deemed ready for cannulation. When orders for cannulation have been received, initial cannulation may be performed by a teammate trained and designated as an Expert Cannulator
Considerations for Mature Arteriovenous fistula (AVF)
A mature fistula is defined as one that has successfully tolerated its prescribed maximum needle gauge and blood flow rate for at least six treatments. At this point, a Proficient Cannulator may begin cannulating this access.
Considerations for Establish arteriovenous fistula (AVF)
An established fistula is one that has been cannulated with both arterial and venous needles for at least two months without signs or symptoms of dysfunction. At this point, a Beginner Cannulator may begin placing this patient’s needles
What is the recommended needle gauge and max BFR for new AVF initial cannulation as ordered by the physician
Needle gauge and suggested BFR:
17: 200 - 250 ml/min
16: 250 - 350 ml/min
15: 350 - 450 ml/min
14: not to exceed 450 ml/min without physician prescription
Consideration for cannulation in regards to the use of one needle and a tourniquet
Use of one needle: Per physician order, used for arterial pull
Use of tourniquet: Used to help engorge fistula and stabilize vessel for cannulation - it should not impede overall blood flow to limb and take care when using on individuals with compromised or thinner skin
Cannulation Rules - Site prep Cannulation Rules - Cannulation
Evaluation of blood flow: Thrill/bruit; look/listen/feel
Site rotation/healing time: 14 days - ‘rope ladder method’ rotation of sites needed to promote healing
Needle insertion:
AVF: 25 degrees
AVG: 45 degrees
Flipping the needle/complications:
Flipping needles is not necessary because the arterial needle has a back eye - flipping needles causes coring of access and can lead to increased bleeding and damage to access (scarring). It’s not a recommended practice.
Distance from anastomosis: 1.5 inches
Distance between needle tips: 1.5 inches
Needle Removal
Angle: same angle as insertion (also follow manufacturer recommendations)
When to apply pressure: when the needle is completely removed
Use of clamps:
- Clamps require a physician’s order. Use ONLY ONE clamp at a time
- Clamp may remain in place for 5-10 minutes before checking to see if bleeding has stopped
- Check access blood flow (thrill and bruit) ABOVE AND BELOW clamp a minimum of every 10 minutes and document
- If bleeding has not stopped, reapply the clamp checking for thrill and bruit above and below the clamp
- Clamp may remain in place for 5-10 minutes before checking to see if bleeding has stopped. Access clamp should not be left on longer than 20 minutes.
- If bleeding persists, the teammate should manually hold pressure on the access site for at least 10 minutes.
- After 30 minutes, if bleeding has not stopped, notify licensed nurse and refer to the policy.
Use of hemostatic sponges: requires order and must be removed prior to patient discharge.
What are BEST TIPS for Complications and Prevention
B: Bleeding
E: Erosion
S: Stenosis
T: Thrombosis
I: Infection
P: Pseudoaneurysm/Aneurysm
S: Steal syndrome
What are PPE Requirements
Gowns, gloves, face shield are required when drawing pre-dialysis labs through the vascular access needle; if CVC add mask to teammate and patient
Successful lab draws
No Handwritten or double label - WILL BE REJECTED
Follow order of lab draw to avoid contamination of additives in tubes that will affect other tubes
What are the steps of processing for labs
Clotting Time: Follow the requisition label
Rules for spinning samples: Follow requisition - must balance centrifuge
When to refrigerate: Follow requisition (some are immediate and not spun)
When NOT to refrigerate: Culturettes/swabs/occult stool - follow directions
Training requirements for shipping: IATA
What is the goal for Single Pool (spKt/V) for 3x/week frequency of dialysis treatments?
Greater than or equal to 1.2
What is Kt/V
K: Clearance of Urea
- Treatment factors that DECREASE K: Inadequate coagulation, decreased BFR, poor priming, not following P&P, patient not staying on treatment as prescribed.
- Treatment factors that INCREASE K: Increased BFR, correct DFR, correct dialyzer, correct target weight - amputation factor
t: Time of dialysis session
- Factors that influence ‘t’: Running prescribed treatment time, following physician orders - encouraging the patient to run the entire treatment. Getting off early will impact time (missing treatment also impacts treatment time)
V: Volume of urea distribution/volume of pts body water in which urea is distributed
- Factors that influence ‘V’: Amputation, height, sex, age, and type of access (less efficient access reduces the volume process of a patient’s blood)
Procedure for Post BUN lab draw
Verify that dialysis has been initiated for approximately 30 minutes with blood flow rate set as prescribed
Turn off UFR or decrease it to 50 ml/hr
Decrease DFR to 300 or put in bypass
Decrease BFR to 100 ml/min
Wait 15 seconds for all access types and draw post
Lab draw mistakes that would falsely increase Kt/V
BFR not reduced
Waiting only 5 secs
Drawing post BUN from venous line
Lab draw mistakes that would falsely increase Kt/V
BFR not reduced
Waiting only 5 secs
Drawing post BUN from venous line
Lab draw mistakes that would falsely decrease Kt/V
Accidentally diluting pre-treatment arterial BUN blood sample with saline, waiting for longer than 15 seconds to draw blood sample
A sudden decrease in blood pressure can be an indication that the patient is losing intravascular fluid too quickly, what is this change equal to
> or = 20mmHg
Pre-pump arterial pressure that becomes too negative can cause hemolysis what should the arterial pressure not exceed?
-260mmHg
What 2 steps are performed to replace fluid removed and prevent clotting during the recirculation of blood in the extracorporeal circuit when there has been a treatment interruption (i.e. the patient using the restroom)
The saline infusion line is opened and if the patient receiving an intradialytic heparin infusion via the dialysis machine, the heparin pump remains on.
