Question

a) What does the nurse use in the evaluation for the parameters for dialysis? (i.e. electrolyte remover, Transmembrane pressure) Provide two specific, definable, and measureable evaluation parameters.

b) Describe the documentation that is required during dialysis. Provide examples of the required documentation pieces during dialysis: patient condition pre, during, and post, and one example of machine documentation pre and post. Also include the process of de-accessing the site.

c) Overtime, dialysis causes the heart to become sluggish. Describe how the process of dialysis correlates with heart function. Provide a description of how the process of dialysis correlates with structure, electricity/conduction, and plumbing of heart function.

d) Discuss the outcomes of toxin removal, fluid removal, and electrolyte balance correction. Provide a description.

Answer 1

A. Evaluation parameters of dialysis

There is a non-invasive assessment tool that can monitor the amount of clearance the patient is recieving during dialysis treatment Online clearance test which take part in two phases:. This uses sodium chloride with a molecular weight of 58, as a surrogate marker for urea

During first half raising the dialysate sodium above normal sodium concntration in the blood as high as 15.5 mS/cm

Second half involves, lowering the dialysate sodium to 13.5 mS/cm, thus allowing the diffusion to take palce . Conductivity monitors are present at the both inlet and outlet of dialyzer, difference in the conductivity is monitored to generate a clearance value

Transmembrane pressure is the hydrostatic pressure gradient which allows for ultrafiltration to remove excess water from blood

B. Pre-dialysis assessment

Before initiation of hemodialysis , both machine and patient are evaluated . The patient's physiologic status is assessed to ascertain the need to adjust dialysis orders or prescribed medications. the machine parameters are assessed to ensure proper implementation of dialysis procedure

Pre-dialysis assessment includes the following:

Related to patient

1. Fliud status assessment: assess for RR and effort, jugular venous distention,heart sounds, breath sounds and presence of edema)
2. Weight has to be recorded with Vital signs ( apical and peripheral pulse evaluation should be done)
3. Blood pressure- sitting and standing should be recorded
4. Skin color, temperature turgor and integrity
5. Vascular access patency and assess for signs of infection
6. Interpretation of physical assessment and laboratory values( S. potassium, sodium, BUN level, creatinine) for appropriate intervention and medication administration

Related to machine

1. Dialyzer membrane check for patency and integrity
2. Blood tubing intact without any leaks
3. Appropriate prescribed dialyzer
4. Dialysate fluid composition as ordered within safe limits (12.8-14-8 mho)- read by myron L meter
5. Temperatur within prescribed range-35 degree-37 degree celcius
6. co-relation of machine conductivity with an external meter reading of dialysate
7. Dialysate delivery sysem free of sterilizer or disinfectant free system
8. Extra corporeal blood circuit free of air
9. Blood pump properly occluded
10. Dialyzer blood line tubings free of kinks
11. Blood pump segment of tubing properly seated in the pump segment
12. Physician orders reviewed to ensure adherence to dialysis prescription
13. All alarms programmed and set within limits
14. Dialysis quality water assessed for chlorine and chloramines

Intradialytic assessment and monitoring

Is the ongoing assessment of patient and machine during hemodialysis.. It includes the following

Machine parameters

1. Arterial Pressure
2. Venous pressure
3. Fluid removal
4. Dialysate flow
5. Blood flow
6. visual check of the dialyzer including tubings and connections
7. Visual check for machine monitoring
8. Heparin pump
9. Visual check for air/foam detector alarm status
10. Visual check for patient's vascular access- for needles insitu and secure

Patient parameters

1. General condition and response of the patient during the procedure
2. Nausea, apprehension, shortness of breath, restlessness or agitation,irritability, flushing, twitching,irrational behaviour, sensation of fainting, pain. A patient on regular dialysis has a pattern of symptoms and any change in the pattern is significant.
3. Acute dialysis patient should be monitored cautiously because of their unknown response to the treatment and their unstable condition
4. All observed clinical conditions are documented and reported to the physician immediately

Post dialytic assessment

Patient parameters

1. Vital signs and  the weightshould be assesed ; weight loss should be recorded
2. Total infusions given, both saline and blood
3. Patient's subjective physical assessment- pain , any complain
4. Check the access site for any bleeding
5. Finalise the next dialysis date

C.Effects of dialysis and heart function

Hypotension is the most commom side effect occurs as result of rapid removal of fluid due to Ultrafilitration. Lack of vasoconstriction due to antihypertensives

Ingestion of food during hemodialysis causes sphlanic vasodilation and lead to hypotension

Hypotension at the begining of dialysis will occur for children and patient's with small blood volume. This can be prevented by infusion of small amounts of saline and albumin carefully

Patients with myocardial damage and those reciving digitalis may develop arrhythmias of various types in response to volume change or rapid shift in electrolytes, particularly potassium