POST DIALYSIS BLEEDING

POLICY: The following procedure will be used to provide a safe and effective means for
controlling prolonged bleeding from an arterial or venous needle puncture site to a
graft or fistula.

DEFINITIONS:

NORMAL BLEEDING- is bleeding which ceases within 15 minutes after the removal of
the fistula needle, using conservative treatment.

CONSERVATIVE TREATMENT-'is holding direct pressure over the needle sites.

PROLONGED BLEEDING- is active bleeding after 30 minutes of conservative

treatment.

PROCEDURE:

1. Remove the fistula needle and using a gauze sponge apply direct pressure over the needle
site. Arm clamps may be placed at this time unless new graft.
2. If the needle site is actively bleeding after 15 minutes of direct pressure, elevate arm and
allow the clamp to remain in place for additional 15 minutes before checking the site.
3. If the site continues to bleed after using the clamp, consider applying 1 Gelfoam or
equivalent over the needle site and reapply pressure over the site with the arm clamp.
Check the needle site after 5 minutes. Do not remove the Gelfoam.
4. If the needle site continues to bleed despite above measures, check the patient's blood
pressure in the other arm. If the blood pressure is elevated for this patient, notify the
physician.
within
5. Continue to use direct pressure. Notify MD if unable to stop bleeding 60
minutes.
6. At this point a cling wrap pressure dressing needs to be applied. Wrap the dressing over
the needle site with the gauze sponge directly over the site. Apply the dressing tight
enough to control the bleeding without cessation of pulse in the access. Notify the
physician regarding additional orders and discharge the patient from the unit.
 BLOOD GLUCOSE DETERMINATION

POLICY: Diabetic Patients will have a blood glucose level checked as ordered by the M.D.
Also blood glucose may be checked prn if the diabetic Patient shows signs or
symptoms of hypoglycemia or hyperglycemia.

EQUIPMENT:
1. 3cc Syringe with needle
2. Glucose monitor (Ames Glucometer III/J&J One-Touch)
3. Blood Glucose monitoring strips (Gluco-film/One-Touch)
4. Tissue if required
5. Betadine wipe.

PROCEDURE:
1. Aspirate 0.3 - 0.5cc of blood into syringe from arterial fistula needle or,
2. Prep medication port (arterial) with Betadine pad (*Use universal precautions).
3. Insert needle into (arterial) Medication port and withdraw 0.3-0.5cc of blood.
4. In the laboratory area, use Ames Glucometer III/J&J One Touch to determine the
blood glucose level of Patient.
5. Document the Glucose value on Patient's Flow Sheet.
 DIALYZER BLOOD LEAK

POLICY: All hemodialysis blood leaks will be handled according to the following
procedure.

EQUIPMENT: 1 - New dialyzer

1 - bag of saline
1 - 10 cc syringe
4 - hemostats
1 - hemastix

IDENTIFYING A BLOOD LEAK: Look for blood leak any time the blood detector alarm sounds.

PROCEDURE:

1. When a blood detector alarm is noted, check the dialysate at dialysate outflow line (red)
with a hemastix. If the stick changes color at all, a blood leak is present.
2 Once a leak is detected, turn off the dialysate flows and return the patient's blood
according to the procedure.
3. Flush the arterial needle with saline to prevent clotting.
4. Once the blood is returned, flush the venous needle with saline to prevent clotting.
5. Clamp the arterial and venous blood lines at the dialyzer and disconnect the dialyzer and
return it to the reuse technician for proper disposal, if re-use dialyzer.
6. Obtain a new dialyzer, and after rinsing the sterilant, recirculate and clear residual
sterilant according to the procedure.
7. Check the dialyzer for sterilant residual and if clear restart the treatment.
8. At the end of this patient's treatment, a mandatory bleach cycle must be completed prior
to the initiation of the next patient's treatment initiation.

If there is not a change in the hemastix, check the dialyzer for air bubbles and clean the blood
detector sensors with gauze.

Note: In the event of a large blood leak (visible blood in dialysate) do not return the Patient's
blood to avoid the possibility of dialysate contamination of the Patient's blood.
 TAKING AND RECORDING BLOOD PRESSURE

POLICY: Blood Pressure will be taken at least every thirty (30) minutes during the
dialysis treatment according to the following procedure.

EQUIPMENT: 1 - stethoscope
1 - sphygmomanometer or automatic blood pressure cuff.

MANUAL ASSESSMENT

PROCEDURE:

1. Take the equipment to the patient and explain the procedure to the patient.
2. Have the patient in a comfortable position with the forearm supported and the palm
upward. Do not use arm with dialysis access.
3. Place sphygmomanometer on a flat surface.
4. Place yourself so that the meniscus of mercury can be read at eye level, and no more that
3 feet away.
5. Place the cuff so that the inflatable bag is centered over the brachial artery (it lies
midway between the anterior and the medial aspects of the arm) so that the lower edge of
the cuff is 2 cm. above the antecubital fossa.
6. Wrap the cuff smoothly around the arm and tack the end of the cuff securely under
wrapping.
7. Use the fingertips to feel for a strong pulsation in the antecubital space.
8. Close the screw valve on the bulb and compress bulb until the mercury rises at 200 or
until the pulse cannot be heard through stethoscope.
9. Using the valve on the bulb, release air 2 to 3 mmHg per heart beat and note the point
on the manometer at which the first sound is heard; recording this figure as the systolic
pressure.
10. Continue to release the air in the cuff evenly and gradually, sounds may become a bit
muffled.
11. Note the reading on the manometer when the last distinct sound is heard. Record this
figure as the diastolic pressure.
12. Allow the remaining air to escape quickly; remove the cuff. Fold and replace in
container. Retake BP if it varies greatly from the previous reading.

AUTOMATIC CUFF ASSESSMENT

1. Position cuff around arm. (see #5, manual assess.)

2. Press start.
3. Record blood pressure.
4. If blood pressure varies greatly recheck.
 BLOOD PRESSURE BY PALPATION

POLICY: Blood pressure by palpation will be taken when it is not audible through the
stethoscope.

PROCEDURE:

I. Place the index and second fingers over the radial artery.
2. Pump the mercury up to 200mmHg and slowly release.
3. When the pulsation is felt, note the systolic reading.
4. Record the blood pressure on the chart. Write that the blood pressure was taken by
palpation.
 COLLECTING BLOOD SAMPLES

POLICY: Blood Sample collection will follow the procedure below.

EQUIPMENT: 1 - Vacutainer
1 - luer-lock adapter needle
Appropriate blood tubes for sample

PROCEDURE:

A. Fistula or Graft
1. Insert dry, nonheparinized fistula needles of desired gauge and length into the
fistula or graft.
2. Tape securely.
3. DO NOT HEPARINIZE THE PATIENT.
4. Connect clean, vacutainer with the luer-lock to one of the fistula needles using
aseptic technique.
5. Insert the blood tube and unclamp the fistula needle (the blood tube will fill
automatically).
6. Remove the blood tube when full.
7. Clamp the fistula needle.
8. Remove the vacutainer.
9. Patient is now ready to be heparinized.
 OBTAINING BLOOD CULTURE

PURPOSE: Used for diagnosis of any symptoms a Patient may experience in suspecting
generalized infection or septicemia. Procedure must be done aseptically.

EQUIPMENT:
1. 2 Yellow top Culture tubes per set (100 mm x 16 mm) or 2 Blood culture bottles
with medium.
2. 1-20 or 30 cc syringe per set.
3. 4 Betadine swabs.
4. Appropriate requisitions.
5. 4 needles per set or 1 vacutainer per set.
6. Labels for tubes with Name, Date, Time Drawn, Patient SS#, specified set I and
Set IL
7. Mask.

PROCEDURE:
1. Explain to Patient reason for procedure.
2. Place mask on Staff Member and Patient (or have Patient turn head away from
arterial line.)
3. Swab each blood culture tube/Bottle with separate Betadine swab. Tubes may be
placed on an open, sterile 4x4 (BE SURE TO KEEP STERILE!)
4. If using syringe, place needle on syringe and draw 20 cc (10cc of blood required
per vial.)
5. Change needles using needle holder on machine, IV pole, and replace with new
needle. Place 10cc blood in 1st vial.
6. Change needle - use new needle to place remaining 10 cc blood in 2nd vial.
7. If drawing a second set, wait 30 minutes if possible and repeat Steps 1-6.
8. Place tubes together with appropriate requisitions and send to lab as designated
by the Dialysis Facility.
9. Document blood drawn on Flow Sheet.
10. Check to make sure MD order is written on Order Sheet.
 BLOOD TRANSFUSION, ADMINISTRATION

PURPOSE: To restore blood volume or oxygen carrying capacity by administering whole

blood, or more commonly during dialysis, packed or washed red blood cells.

EQUIPMENT:
1. Blood with attached I.D. Tag and Blood Set from contracted hospital.
2. Have Patient already on dialysis.
3. Heparin - 500 u/Unit of Blood.
4. 3cc Syringe.
5. 1-BAG N/S for priming blood tubing.

PRE-TRANSFUSION:
1 Patient preparation.
A. Vital signs (TPR and BP).
B. Instruct Patient of possible transfusion reactions. (See Blood Reaction
Policy).
C. Inform Patient to alert Staff of any symptoms of reaction immediately.
2. Blood preparation.
A. Verification of correct blood unit/patient.
1. 2 RN's or RN and M.D. necessary to check and sign blood tag.
2. RN only may administer blood.
3. Check Patient's ID band/sheet with information: Verifying Social
Security Number, blood bag number versus blood tag number. 4.
Sign full signature in appropriate area on blood bag tag.

*NOTE: If any discrepancy in Name or Numbers return Blood to Blood Bank.

B. Prime tubing according to manufactures directions c N/S
C. Close volume control clamps on administration set.
D. Attach tubing to dialysis line tubing - at arterial chamber port.
E. Open gently either outlet on plastic blood container.
F. Insert tubing spike.
1. Rotate spike gently to insert. Use care not to perforate bag.
G. Hang bag on machine IV pole.
H. Open appropriate volume clamp and with filter chambers to cover filter
with blood.
1. To prevent formation of air bubbles and to utilize entire filter.
I. Run blood through entire tubing and clamp.

*NOTE: Our set can be used for more than 1 unit of blood if properly rinsed with N/S between
units.
 START TRANSFUSION:
1. Test dose (approximately 10-15 cc's)
A. If no GI bleed, suspect Bolus 500u Heparin in arterial line just prior to
start of each Unit.
B. If GI bleed suspected and Patient is on 0 Heparin, hold Heparin bolus;
rather flush kidney with N/S every 15 minutes to 30 minutes using RN's
discretion.
C. Remember to add these flushes into total fluid removal goal.
2. Chart on Flow Sheet.
A. Time test dose given.
B. Bag Number.
C. That Patient was explained S/S of reactions.
D. Signature of RN starting transfusion.
3. 15 minutes after test dose
A. Observe Patient for any S/S of reaction.
B. Repeat vs (TPR and BP) and chart on Flow Sheet.
C. Verbally ask Patient how he/she feels.
D. If no reaction, proceed with transfusion.

AFTER TEST DOSE:

A. Blood may be bolused in 1/3 increments over remaining 45 minutes.
B. Blood may be dripped in over remaining 45 minutes using drop factor formula
to assure proper number drops/min or ml/hr.
1. Observe blood frequently if dripping as set rate may change with line
pressure.
2. Be sure to double clamp lines (1 on blood tubing, 1 on arterial line).
C. Blood should not run more than 4 hours or less than 1 hour without checking with
Physician.
D. In general, blood unit should be infused within 2 hours.
E. Keep blood on ice in cooler when not infusing.

ADVERSE SIGNS:
A. If any signs of reaction, discontinue immediately. (See reaction procedure).

END OF TRANSFUSION
A. D/C when blood is infused.
B. Obtain post vital signs and chart along with time ended and amount transfused.
C. Remove tag from bag and fill out appropriately.
D. Keep tag copy for chart and return bottom copy to Blood Bank.
E. Return Blood Bag to Blood Bank or keep in refrigerator for 48 hours.
F. Document on flow sheet.
 POST BLOOD ADMINISTRATION PATIENT INSTRUCTIONS

The blood you received during your transfusion was supplied by the American Red
Cross. Side effects of blood transfusions are rare but can occur, therefore if you develop
any of the following symptoms within the next twelve (12) hours, please call your
physician and inform him of the symptoms you are having and that you have recently
received blood.

Fever
Chills
Chest Pain
Nausea/Vomiting
Shortness of Breath or trouble breathing

If you notice any of the following symptoms within the next three (3) weeks, please
notify your physician.

Very dark urine (darker than normal for you)

Yellow skin or eyes
 BLOOD ADMINISTRATION - REACTION AND TREATMENT

POLICY: All possible blood reactions will be treated according to the following procedure:

TYPES AND ADVERSE REACTIONS:

I. Febrile Reaction: Onset is generally during the transfusion or up to 24 hours post
transfusion in patients who have had multiple transfusions.

A. SYMPTOMS
1. chills
2, fever
3 headache
4. nausea
5. non-productive cough
6. hypotension, chest pain, vomiting and dyspnea (these occur less
frequently)

B. TREATMENT
1. Treatment is generally not required however, if reaction occurs during the
administration, blood should be discontinued and the physician notified
before the transfusion is started again.

II. Allergic Reaction: Onset is generally during the transfusion or up to 24 hours post
transfusion.

A. SYMPTOMS
1. Urticaria (appearance of intensely itchy wheals or welts with elevated,
usually white centers and a surrounding area of erythema).
2. Itching
3. Less common are swelling of the face and asthma symptoms.
4. Anaphylaxis - a severe reaction.

B. TREATMENT
1. Discontinue transfusion and notify the physician.
2. Antihistamines may be ordered po or I.M.

III. Hemolytic Reaction: Onset may be immediate and rapid or after infusion of several units.
A. SYMPTOMS
1. Apprehension
2. Fever
3. Chills
4. Headache
 5. Shock
6. Nausea
7. Vomiting
8. Dyspnea.
9. Flushing
10. Sense of impending danger

B. TREATMENT:
1. Discontinue transfusion and notify physician.

IV. Hemolytic Reaction: Delayed onset, may be several days or several weeks post
transfusion.
A. SYMPTOMS
1. Drop in hematocrit
2. Mild jaundice
3. Fever

B. TREATMENT
1. Usually none, unless HCT value critical.

V. Circulatory Overload: Onset is generally gradual with increasing symptoms during

transfusion.
A. SYMPTOMS
1. Cough
2. Shortness of breath
3. Neck vein distention
4. Pulmonary congestion
5. Edema
B TREATMENT
1. Discontinue transfusion. If the patient is dialyzing, the fluid may be removed
rapidly by ultrafiltration. If the patient is not dialyzing, treatment usually consists of
keeping the head elevated, nasal 02 and obtaining further orders from the
physician.

VI. Miscellaneous Reaction

A. Transfusion of Contaminated blood: rapid onset, reaction may be fatal.

1. SYMPTOMS
a. Elevated pulse
b. Hypotension
c. Temperature elevation
d. Chills
 e. Shock
2. TREATMENT
a. Discontinue the transfusion and notify the physician for further
instructions or orders.

B. Rapid transfusion of large amounts of stored blood: Reactions are rare. There are
generally no problems unless patient's K+ level is critical.

NOTE: If a transfusion reaction occurs: Draw a blood sample from patient, keep blood bag
and return sample and bag to blood bank for testing.
 CALCIJEX PROTOCOL

POLICY: All patients receiving Calcijex will be monitored according to the following
procedure.

PROCEDURE:

1. Administered I.V. bolus through the venous medication port at the end of the
hemodialysis treatment only by an R.N. or L.P.N. during last 30 minutes of dialysis.
2. The dose may be increased every two to four weeks if the initial dosage is not sufficient
to increase the calcium level, dose adjusted per M.D.

CONTRAINDICATIONS:

1. Hypercalcemia-chronic hypercalcemia can result in vascular calcification,

nephrocalcinosis, and other soft tissue calcifications.
2. Vitamin D toxicity, early signs and symptoms are weakness, headache, somnolence,
nausea, vomiting, dry mouth, constipation, muscle pain, bone pain, and metallic taste in
mouth. Late signs and symptoms are weight loss, conjunctivitis, photophobia, pruritis,
hypertension, cardiac arrhythmias.

MONITORING:

1. Serum calcium and phosphorus levels should be monitored monthly or as ordered.

INFORMATION FOR THE NURSE:

1. Calcijex is a synthetically manufactured calcitriol, a potent form of Vitamin D3 used in

the management of hypocalcemia in patients undergoing chronic renal dialysis. It has
been shown to significantly reduce elevated parathyroid hormone levels in many of these
patients.
 CODE DRUGS

POLICY: To familiarize the R.N. with the most commonly ordered drugs used during a
cardiac/respiratory arrest according to the following procedure.

The American Heart Association (AHA) offers a useful classification of code drugs based on
therapeutic objectives.

OBJECTIVES:

1. To correct hypoxemia and acidemia: sodium bicarbonate.

2. To increase perfusion pressure, enhance contractility and restore heartbeat: epinephrine,
calcium chloride.
3. To accelerate heart rate in cases of bradycardia: atropine, isoproterenol (Isuprel).
4. To correct ventricular dysrhythmias: lidocaine, procainamide, bretylium.
5. To raise blood pressure and cardiac output: dopamine, norepinephrine (Levophed).

I. SODIUM BICARBONATE
Correcting hypoxemia is the primary therapeutic objective for most patients in cardiac
arrest. Without adequate oxygenation, all other treatments are useless since untreated
hypoxemia will cause cerebral and myocardial ischemia and eventual necrosis:

To treat hypoxemia, the highest possible concentration of oxygen must be given by the
most direct route, either by a bag-value-mask or endotracheal intubation. High
concentrations of oxygen are required because CPR, even when correctly performed,
cannot restore more than 30% of normal cardiac output.

Oxygen has another beneficial result: because it improves tissue perfusion, cells are not
required to resort to anaerobic metabolism to survive. Anaerobic metabolism produces
lactic acidemia. H. this cycle continues indefinitely severe acidemia occurs and cells will
die. Sodium bicarbonate helps counteract the lactic acidemia caused by untreated
hypoxemia.

AHA recommends a loading dose of 1 mEq of Sodium bicarbonate per kg of body

weight. The usual range for the loading dose is 50-100 mEq (1-2 ampuls) by IV push.
Never infusion. Then 25-50 Meq (1/2-1 ampuls) every 10 minutes.