Observation Report:

Hemodialysis Ward
By: Kit P. Roaquin, RN

1. Describe assessment protocols and findings of the dialysis patient during hemodialysis
Assessment/Data Collection Ask the patient predialysis for any trauma, vomiting, Diarrhea, breathing difficulty a. Predialysis and Postdialysis: obtain the following directly and personally:
1. 2. 3. 4. Weight; The patient(s) may not report the weight to staff. Vital signs: temperature, apical pulse, respirations, blood pressure; orthostatic blood pressure post treatment and prn. Fluid volume: edema, especially facial and lower extremity, jugular venous distention, turgor, ascites, breath sounds, crackles, wheezes. Vascular access site: a) Change in characteristics of bruit/thrill (fistula/graft) b) Patency C) Signs and symptoms of infection (oral temperature greater than 99.5 F, erythema at the site, purulent drainage, complaints of pain and discomfort, swelling) Mental status Patient complaints of: chest pain, shortness of breath, severe weakness, severe cramping, persistent swelling in graft extremity or any other problems/difficulties experienced since the last dialysis treatment. 0-10 on pain scale.

5. 6.

b. During dialysis: assess the following every hour and prn: (unless Nephrologist asks for more frequent monitoring).
1. 2. 3. 4. 5. Vital signs: blood pressure (also immediately after initiating dialysis); prn apical pulse if indicated; Mental status; For complaints of dizziness, cramping, nausea; For patients with catheter access, see Hemodialysis Venous Access Catheter Protocol; Assess every hour: access site: patent and intact, functioning, infiltration/hematoma, unusual pain

2. List and explain complications of hemodialysis and assessment findings of each complication as covered in the text of hemodialysis
A. Hypotension
A decrease in blood pressure is the most frequent complication reported during hemodialysis. When fluid is removed during hemodialysis, the osmotic pressure is increased and this prompts refilling from the interstitial space. The interstitial space is then refilled by fluid from the intracellular space. Excessive ultrafiltration with inadequate vascular refilling plays a major role in dialysis induced hypotension. The immediate treatment to hypotension is to discontinue dialysis and place the patient in a trendelenburg position. This will increase cardiac filling and may increase the blood pressure promptly.

B.

Cramps
In the majority of hemodialysis patients, cramps occur toward the end of the dialysis procedure after a significant volume of fluid has been removed by ultrafiltration. The immediate treatment for cramps is directed at restoring intravascular volume through the use of small boluses of isotonic saline. Prevention of cramps has been attempted with the prophylactic use of quinine sulfate at least 2 hours prior to dialysis.

C.

Febrile reactions
Febrile episodes should be aggressively evaluated with appropriate wound and blood cultures. The suspicion of infection should be high. Treatment of endotoxin related fever is generally supportive withantipyretics. Temperatures should be recorded at the initiation and termination of dialysis treatment.

2. List and explain complications of hemodialysis and assessment findings of each complication as covered in the text of hemodialysis

D.

Arrhythmia
Patients on maintenance hemodialysis are at risk of cardiac arrhythmias. They occur predominately in association with hemodialysis or may occur in the interdialytic period. Both acute and chronic alterations in fluid, electrolyte, and acid-base homeostasis may be arrhythmogenic in these patients.

E.

Hemolysis
Hemolysis may result from a number of biochemical and toxic insults during the dialysis procedure. The half-life of red blood cells in renal failure patients is approximately one half to one third of normal and the cells are particularly susceptible to membrane injury.

F.

Hypoxemia
A fall in arterial PO2 is a frequent complication of hemodialysis that occurs in nearly 90% of patients. The drop ranges from 5 to 35 mm Hg, and reaches its peak between 30 - 60 minutes after beginning dialysis. This is obviously undesirable for patients with underlying cardiopulmonary disease. Also, patients on mechanical ventilators with constant minute volume and inspired oxygen concentration can still develop hypoxemia during hemodialysis.

3. What assessment findings were observed that alerted the nurse to complications during dialysis? If no complications occurred during dialysis, describe one possible complication and address that one.

Dialysis Disequilibrium Syndrome

Characterized by nausea, vomiting, headaches, and fatigue Can result in life-threatening seizures, coma, and arrhythmias Pathogenesis from rapid rates of change in solute concentration and pH in the central nervous system Most commonly occurs with high initial solute concentrations

Treatment strategies to reduce disequilibrium

Use of smaller surface area dialyzers Reduced rates of blood and dialysate ow Cocurrent (rather than countercurrent) dialysate ow High dialysate sodium Intravenous administration of diazepam

4. Describe common laboratory diagnostic tests to evaluate the patient. Which tests are evaluated weekly, monthly or annually?

Creatinine

5. Describe dietary management, fluid restrictions, and dietary goals for a patient observed.
Dietary Management
1. Diet high in sodium must be avoided because it can make one thirsty and thereby cause the body to hold on onto more fluid. In order to cut down on salt intake one may have to flavor his/her food with herbs and spices instead of common salt. 2. Foods rich in phosphorus e.g. dairy products, nuts, beans, lentils, cola drinks, beer, and cocoa drinks are most likely to increase the phosphorus level in the blood. Unfortunately however, dialysis is unlikely to remove accumulated levels of phosphorus in the blood and this can cause the release of calcium from the bones. The continuous removal of calcium from the bones may eventually make them weak causing brittle bones. It is also known that high accumulation of phosphorus in the blood results in the formation of what is called calciumphosphorus crystals in the joints, muscle, blood, heart etc. The calcium-phosphorus crystals may pose problems such as bone pain, poor blood circulation and even damage to the heart. 3. Equally, persons undertaking hemodialysis may have to limit the intake of foods rich in potassium. Foods high in potassium include bananas, melons, oranges, potatoes, tomatoes, milk, poultry, pork and fish.

5. Describe dietary management, fluid restrictions, and dietary goals for a patient observed.

Fluid Restriction
1. Factors that can lead to increased intake of fluids must be watched and avoided. Fluids include any food or beverage that remains liquid at room temperature, for example gravy, soups, ice cream, tea, coffee, juices, water, fizzy drinks.

6. Compare the findings in Q#5 with the text or other recommended reference on dietary management for patients with ESRD.

7. List and describe the purpose of current medication on one patient observed.
Drug Norvasc (amlodipine besylate) Classification Calcium Channel Blocker Mechanism of Action
These medications block the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. Since calcium is important in muscle contraction, blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body.

Indication
Chest pain or heart pain (angina) occurs because of insufficient oxygen delivered to the heart muscles. Insufficient oxygen may be a result of coronary artery blockage or spasm, or because of physical exertion which increases heart oxygen demand in a patient with coronary artery narrowing. Amlodipine is used for the treatment and prevention of angina resulting from coronary spasm as well as from exertion. Amlodipine is also used in the treatment of high blood pressure.

7. List and describe the purpose of current medication on one patient observed.
Drug Renvela (sevelamer-oral) Classification Phosphate Binder Mechanism of Action
Renvela (sevelamer carbonate) soaks up and holds on to (or binds) the phosphorus found in the foods. It then carries phosphorus out of the body through the digestive system.

Indication Renvela is used to control phosphorus levels in patients with chronic kidney disease (CKD) on dialysis.

7. List and describe the purpose of current medication on one patient observed. Drug Classification Mechanism of Indication Action
(sodium bicarbonate) Antacid
Sodium bicarbonate reduces stomach acid. It is used as an antacid to treat heartburn, indigestion, and upset stomach. .This medication may be used to make the urine less acidic. This medication may be used to make the urine less acidic. This effect helps the kidneys get rid of uric acid, thereby helping to prevent gout and kidney stones. Sodium bicarbonate is indicated to treat metabolic acidosis and to alkalinize the urine. It is also used as adjunctive therapy in treating hypercalcemic or hyperkalemia crises.

7. List and describe the purpose of current medication on one patient observed. Drug Classification Mechanism of Indication Action
Plavix (clopidogrel) Antiplatelet
Inhibitor of ADPinduced pathway for platelet aggregation. Plavix Oral is used to treat myocardial reinfarction prevention, non-Q wave heart attack, acute ST elevation myocardial infarction, acute syndrome of the heart, unpredictable severe constricting chest pain, prevention for a blood clot going to the brain, treatment to prevent peripheral artery thromboembolism.

7. List and describe the purpose of current medication on one patient observed. Drug Classification Mechanism of Indication Action
Plavix (clopidogrel) Antiplatelet
Inhibitor of ADPinduced pathway for platelet aggregation. Plavix Oral is used to treat myocardial reinfarction prevention, non-Q wave heart attack, acute ST elevation myocardial infarction, acute syndrome of the heart, unpredictable severe constricting chest pain, prevention for a blood clot going to the brain, treatment to prevent peripheral artery thromboembolism.

8. Develop a nursing care plan addressing three priority nursing diagnoses. Include nursing interventions with supporting rationale and patient outcome.