Module 3 Medication & Pharmacology, Water Treatment/Testing & Dialysate, Patient & Machine Complications, Emergencies

Question 1

Labeling & Expiration of Multi-dose medication vials

Answer 1

Must be labeled with the initials of the person opening the vial and the date it was opened (must be discarded within 28 days after opening except when the manufacturer specifies differently such as Epogen at 21 days

Question 2

Needle/Syringe/Vial of Multi-dose medication vials

Answer 2

The vial may be entered more than once but requires a new sterile needle and syringe to puncture each medication vial to avoid pooling of medication from different vials

Question 3

Regarding single-dose medication vials:

Answer 3

Must be used for only one patient
Each vial should only be entered once and then discarded
The same syringe may be used to enter up to two single use vials of the same medication and concentration to constitute the prescribed patient dose

Question 4

What are the six rights of medication administration?

Answer 4

Time
Route
Amount
Medication
Patient
Documentation

Question 5

What are the four medications that PCTs can administer per DaVita P&P?

Answer 5

Normal Saline
Heparin (if allowed per state regulations)
Lidocaine
Topical Anesthetic Spray

Question 6

At what time are medications containing a preservative discarded?

Answer 6

28 days (except when the manufacturer specifies differently such as Epogen multidose vial (MDV) at 21 days)

Question 7

What size needle with the appropriately sized syringe should be used when drawing up heparin?

Answer 7

21g x 1in

Question 8

Why would the nephrologist order a formulary exception of Citrasate or CitraPure dialysate concentrate?

Answer 8

To use as part of anticoagulation therapy during the dialysis treatment when heparin is contraindicated

Question 9

How do you verify your needle is not in the access when administering Lidocaine?

Answer 9

Aspiration (pull back) of syringe plunger and you do not see blood in the syringe

Question 10

How do you administer Topical Anesthetic Spray?

Answer 10

Wash Access site
Clean site per P&P
Spray topical anesthetic to each cannulation site for 4-10 seconds from a distance of 3-7 inches
the skin will begin to turn white

DONT FROST THE SKIN - Numbing effect occurs with blanching

Question 11

What is the time frame during which single-use medications should be prepared and administered?

Answer 11

Within 4 hours (unless your state specifies another time limit)

Question 12

What are two reasons for water treatment?

Answer 12

Prevent equipment damage
Patient Safety

Question 13

Aluminum in water used dialysis causes

Answer 13

Anemia
Bone Disease
Nausea
Vomiting

Question 14

Chlorine in water used hemodialysis causes

Answer 14

Hemolysis

Question 15

Excess Calcium and Sodium in water used dialysis causes

Answer 15

Hypertension

Question 16

Excess calcium and magnesium in water used for dialysis causes

Answer 16

Muscle weakness

Question 17

What does the RO remove?

Answer 17

Organic and inorganic materials
bacteria
endotoxins

Question 18

What are two concerns with using DI Tanks?

Answer 18

Exhaust quickly
When exhausted they dump/release previously removed ions back into the water

Question 19

Response to Final Water Quality Alarm

Answer 19

Bypass
Notify Charge Nurse/FA/Biomed/Medical Director
If not restored must terminate treatments and complete REM

Question 20

Water/Dialysate culture results

Answer 20

Acceptable level: below 50 cfu/mL
Action Level: 50-99 cfu/mL
Unacceptable level: 100 cfu/mL or >

Question 21

Water endotoxin testing results

Answer 21

Acceptable level: below 0.12 EU/mL
Action Level: 0.12 to < 0.25 EU/mL
Unacceptable level: 0.25 EU or >

Question 22

Dialysate endotoxin testing results

Answer 22

Acceptable level: <0.25 EU/mL
Action Level: 0.25 to <0.50 EU/mL
Unacceptable level: 0.50 EU/mL or >

Question 23

How often are water and dialysate cultures drawn and monitored for bacteria and endotoxins?

Answer 23

Monthly

Question 24

What removes chlorine/chloramines

Answer 24

Carbon Tanks

Question 25

Chlorine/Chloramine testing

Answer 25

When: Always test while the RO is actively supplying water - After the RO has operated for at least 15 minutes first thing in the morning, before the first shift of patients, and every 4 hours Where: After primary carbon tank sample port Acceptable result: Less than or equal to 0.1mg/L Action if results are too high post-primary tank: Repeat the test - if still too high - move onto secondary port and test, remember to notify biomed and FA F/U if secondary test results are within limits: Every 30 minutes F/U if secondary test results are too high: Stop Dialysis by placing dialysis delivery system into bypass - do not rinse patients' blood back

Question 26

What is the purpose of the water softener in Hardness Testing

Answer 26

To remove hard minerals such as calcium and magnesium

Question 27

What is removed and why is this important in Hardness Testing

Answer 27

For RO protection

Question 28

When do we test for Hardness

Answer 28

End of Day

Question 29

Who must be notified when a patient fall has been witnessed

Answer 29

The licensed nurse must be notified so the patient can be assessed

Question 30

Hypotension

Answer 30

Systolic BP <90 Diastolic BP<50 or drop in systolic more than 20 mm/hg

Question 31

Causes of Hypotension

Answer 31

Rapid or inappropriate fluid loss Antihypertensive drugs Low blood volume Food ingestion Unstable cardiovascular condition

Question 32

Symptoms of Hypotension

Answer 32

Flushing Yawning Dizziness Ringing in the ears Tachycardia Anxious feeling Nausea/vomiting Cold clammy skin Seizures Cardiac arrest Visual complaints

Question 33

Hypotension Intervention

Answer 33

Place patient in supine position Decrease UFR to minimum or turn off Water for less severe hypotension 100-200 mL NS for severe hypotension (NOTE: dialysis patient care technicians (PCTs) may give up to 200 ml of normal saline allowed per state and local Board of Nursing regulations) Inform the licensed nurse for further evaluation and intervention Monitor BP

Question 34

Hypotension Prevention

Answer 34

Frequent assessment of target weight Limit UFR to

Question 35

Consequences of Organ Stunning

Answer 35

Heart: Acute stress on the cardiovascular system, development of left ventricular regional wall motion abnormalities (RWMAs), and arrhythmias, can lead to cardiac failure Gut: Releases endotoxin into circulation, inflammation Kidneys: Causes fibrosis, loss of residual renal function Brain: Causes multiple sites with white matter injury

Question 36

Hypertension

Answer 36

Pre-dialysis adult BP is >140/90 Post is > 130/80

Question 37

Hypertension Causes

Answer 37

Disease process Fluid Overload Non-adherence with medication renin-angiotensin cycle

Question 38

Hypertension Symptoms

Answer 38

No symptoms Headache Dizziness Irritability Blurred vision Nervousness Edema - Secondary to fluid retention

Question 39

Hypertension Intervention

Answer 39

Take medications as prescribed Maintaining fluid balance (avoid excessive IDW gains)

Question 40

Hypertension Prevention

Answer 40

Promote fluid and medication adherence

Question 41

Muscle Cramps

Answer 41

Painful muscle contractions in extremities or abdomen

Question 42

Causes of Muscle Cramps

Answer 42

Rapid or excessive fluid removal Hypo-osmolality Tissue Hypoxemia/Ischemia Electrolyte disorders or imbalances: low sodium, calcium, potassium, magnesium, any local irritating factor or metabolic abnormality of a muscle (e.g., severe cold, lack of blood flow, over exercise)

Question 43

Muscle Cramp Symptoms

Answer 43

Painful cramps usually occur late in dialysis

Question 44

Muscle Cramp Intervention

Answer 44

Massage or apply opposing force Stretching of affected muscle Discontinue UFR Provide supplemental oxygen per nephrologist order Assess target weight For severe cramping: a Normal Saline bolus maybe be indicated as prescribed

Question 45

Seizures

Answer 45

Involuntary muscle spasms and loss of conciousness

Question 46

Causes of Seizures

Answer 46

Some patients have seizures as a dialysis side effect (severe hypotension, dialysis disequilibrium syndrome) or seizures may occur during dialysis as an adverse reaction to a problem such as the use of improperly prepared dialysate. Some patients may have a pre-existing seizure disorder

Question 47

Seizure Symptoms

Answer 47

Change in level of consciousness Twitching and jerking movements of the extremities

Question 48

Seizure Intervention

Answer 48

Protect patient and access arm from harm Protect airway Do not pry open clenched jaws once seizure has begun Do not attempt to insert anything into the mouth Treat hypotension Dialysis disequilibrium syndrome Hypoglycemia if indicated Administer oxygen Provide airway support Discontinue Dialysis if no response to interventions

Question 49

Seizure Prevention

Answer 49

Prevent Hypotension Prevent large drops in BUN Monitor for therapeutic drug levels in patients with pre-existing condition

Question 50

Dialysis Disequilibrium Syndrome (DDS)

Answer 50

A condition in which rapid or drastic changes in the patient's extracellular fluid affect the brain

Question 51

DDS causes

Answer 51

Missed treatment Rapid drop in BUN

Question 52

DDS Symptoms

Answer 52

Headache Hypertension Nausea Restlessness Seizures Confusion Blurred Vision

Question 53

DDS Intervention

Answer 53

Slower BFR and DFR than CKD patients Shorter Initial treatments

Question 54

DDS Prevention

Answer 54

Early Recognition of mild symptoms Decrease efficiency of dialysis by: - Use a less efficient dialyzer - Decrease treatment time - Decrease BFR and DFR during treatment - Shorter, more frequent dialysis

Question 55

Fever & Chills

Answer 55

Any temperature greater than 100*F (37.8*C) or increase over baseline of 2*F(1*C) with symptoms

Question 56

Fever & Chills Causes

Answer 56

Systemic infections Access infections Contamination of blood or dialysate compartments Pyrogenic reactions

Question 57

Fever & Chills Symptoms

Answer 57

Nausea Vomiting Headache Hypotension Tachycardia Hot flushed skin Dry mucous membranes

Question 58

Fever & Chills Intervention

Answer 58

The nurse must assess and evaluate the patient for a possible cause of fever Notify the treating nephrologist and if ordered by the physician, obtain blood culture(s) per procedure and send them to the laboratory Provide comfort measures, and administer antipyretics as ordered Administer antibiotics as ordered Schedule patient for permanent access evaluation

Question 59

Fever & Chills Prevention

Answer 59

Avoid use of femoral catheters Evaluate teammates' technique

Question 60

Pyrogenic Reaction