FRESENIUS PCT NEW HIRE EXAM
List three blood borne pathogens that may be found in a dialysis unit.
Hepatitis B, Hepatitis C and HIV
What causes renal osteodystrophy (bone disease)?
No longer produce calcitriol - the active form of Vitamin D o Inadequate or lacking calcitriol causes demineralization of the bone - bone begins to break down to release the calcium needed for body functioning No longer excrete excess phosphorus (PO4) o Phosphorus is found in most foods and beverages o Increased PO4 levels cause further calcium bone loss
Which additional check is performed weekly and before the first treatment after disinfection?
Residual bleach
What are the anatomical structures of the urinary system in order of urine flow?
(2) Kidneys, (2) ureters, (1) bladder, (1) urethra.
Do not initiate any patients treatment if the total chlorine is greater than?
0.1 ppm or greater
List four things you can teach a patient to prevent their access from clotting?
1. not to wear tight fitting clothing or jewelry on the access arm, 2. not to sleep on the access arm, 3. not to let anyone draw labs or check blood pressures in their access arm and, 4. not to carry heavy objects in their access arm.
Steps when taking a post BUN at the end of tx?
1.) Turn off UF & DFR 2.)Turn blood pump speed down to 100 3.) Wait 15 sec 4.) Stop the blood pump 5.)Clamp venous and arterial line 6.) Wipe the arterial port
recommend weight gain for pt?
1.5-2.0 kg/day
A patients antibodies have to be above what to sit in the 4 chair buffer zone?
10
How much water must you collect for the total chlorine test?
100 ml
Normal conductivity range for dialysate?
12.6-15.9
Formula for max amount of fluid that can be taken off each treatment?
13*EDW* HRS of TX= MAX AMOUNT
How long must RO machine run before performing any total chlorine testing?
15 mins
Total chlorine testing for a central water system must be performed and documented by?
2 staff members one being the nurse in charge
How long must you rub hand sanitizer?
20 - 30 sec
How long must you wait before you can read the RCP chlorine strip once you removed it from the water?
20 secs
An arterial pressure reading of negative _____ can cause blood to hemolyze.
270
After the Heparin has been given, how long must you wait before initiating the treatment?
3 - 5-minute
How long should you clean the patients skin before cannulation with alcohol pad or betadine?
30 seconds, if betadine is use allow for it to dry 3-5 mins
Normal Temp Range for dialysate?
35.5-39 'c
How long must you wash your hands?
40-60 sec
What volume should be used for fresh fill/run off?
50 ml of saline should be drained from the arterial line and 250 ml should be drained from the venous line
Normal PH range for dialysate?
6.9-7.6
How long do you allow the RPC to immerse in a sample?
60 secs
How full should the venous chamber ?
65-75%
How full should the arterial chamber ?
85-95%
BFR & Recommened Needle size?
<300 mL/min 17 gauge 300 - 350 mL/min 16 gauge >350 - 450 mL/min 15 gauge >450 mL/min 14 gauge
What is a semi-permeable membrane?
A membrane made from protein, with small pores or holes. Only certain molecules can fit through.
Where should you place an arterial and a venous needle if it has infiltrated?
A new venous needle should be placed above the infiltration site. For an arterial infiltration the needle may be placed either above or below the infiltrated site.
What is a serious adverse event?
An event that causes serious patient injury, hospitalization or death.
What is an infiltration and how is it treated?
An infiltration is fluid seepage into the surrounding tissue resulting in pain and swelling. Infiltrations are treated with intermittent ice for 24 hours followed by intermittent heat and ice as needed.
Which needle should you pull first for treatment termination?
Arterial
What direction should the needles be placed for dialysis?
Arterial needle can go with or against the flow, and Venous needle has to go with the flow.
The three types of errors associated with a "Just Culture" are
At risk, simple human, and reckless
Formula to determine target wt?
Available wt + rinse back
How many KECN tests can be programmed into OLC?
Between 3-6 tests can be programmed. If a treatment is 3-4 hours in length, 6 tests should be programmed.
What insertion angle should I use for cannulation?
Bevel up - AV graft 45 degree angle - AV fistula 20-30 degree angle also depends on depth of access
What is countercurrent flow?
Blood and dialysate flow in opposite directions
What are two things that change with PT's prescription?
Calcium and Potassium
What should you do if a air embolism occur?
Clamp venous line Off with the blood pump Left side Trendelenburg
What does Kecn stand for?
Clearance affected by conductivity of NA+
What happens to diffusion when dialyzer fibers clot?
Clotted fibers cause the permeability of the fiber to be reduced or eliminated, causing a decrease in treatment adequacy. As a result , diffusion does not occur as particles cannot diffuse across the membrane.
What is conductivity?
Conductivity is the ability of a solution to transmit or "conduct" an electrical current
What is crenation and what causes it to occur?
Crenation is the shriveling of red blood cells caused by too high of a concentration of sodium in the dialysate (hypertonic dialysate).
Why is dextrose added to the dialysate?
Dextrose, a form of glucose, is added to prevent hypoglycemia.
What is dialysate?
Dialysate is a non-sterile solution and its function is to remove waste products from the blood and balance electrolytes
Elements that affect the clearance?
Dialyzer, Tx time, Needle size, BFR, Heparin, temperature, DFR
At what point during the hemodialysis treatment will diffusion cease to occur?
Diffusion will continue throughout the dialysis treatment until the concentration of each electrolyte found in the patient's blood is equal to the electrolyte concentration in the dialysate.
Fluid removed during hemodialysis comes from which body fluid compartment?
During dialysis fluid is removed from the intravascular fluid compartment or bloodstream.
What are electrolytes?
Electrolytes are charged particles that can conduct an electrical current. Electrolytes in the body control motor, muscle and nerve function, and maintain the body's homeostasis.
What is Heparin and why is it used in hemodialysis?
Heparin is an anticoagulant that prevents clotting
CVC Disadvantages?
Higher potential for air embolism Prone to infection and clotting Last option and sometimes only option for patients Lower BFRs=increased treatment time to improve adequacy Long-term use can lead to major vessel stenosis Reversing the lines will cause increased recirculation and decreased adequacy
Why is it important to determine which side is arterial and which side is venous?
If the needles are connected to the wrong blood line, recirculation will prevent the clearance to deliver an adequate treatment.
CVC advantages?
Immediate use after verification of placement Higher No need for patient to achieve hemostasis at the end of treatment
How is a large/major blood leak treated?
In the case of a large/major blood leak, where the dialysate appears bloody or blood tinged, do not return the blood
Av graft disadvantages?
Increased rate of stenosis; increased clotting Increased infection rates Increased bleed time at the end of a treatment Require replacement, especially if the cannulation sites are not rotated No collateral circulation develops
How can you tell if a dialyzer is clotting?
Indications of a clotting dialyzer are a rising TMP, rising venous pressure, dark blood in the dialyzer, and air detector alarms. A venous line that is clotting will show an increase in venous pressure.
What's the chain of infection?
Infectious agent, reservoir, portal of exit, means of transmission, entry, host
What are the body fluid compartments?
Intracellular-inside the cells • Extracellular-outside the cells • Intravascular-inside the blood vessels • Interstitial-between the cells
What is Kt/V?
It is a measurement of how well we are cleaning wastes from our patients' blood
What causes increased arterial pressure?
Kinks, clamp or occlusion on arterial line BFR exceeds vascular access flow Needle gauge size selected compared to BFR Needle placement Clotting, stenosis, vasoconstriction or vasospasms Malposition of catheter tip, constricting sutures at insertion site or CVC thrombus Hypotension Poor cardiac output Increased blood viscosity due to high hgb or ultrafiltration
What causes increased venous pressure?
Kinks, clamp or occlusion on venous line Infiltration or poor needle placement Clotting in: Needle CVC Venous chamber lines or dialyzer Machine malfunction Wet or bloody transducer protectors Venous infiltration
What causes muscle cramps during dialysis?
Large amounts of fluid removal Rapid sodium and / potassium changes in the muscle fibers Vasoconstriction/Cramping may occur at any time during treatment; most frequently observed mid to late in the treatment. Cramping can occur in any muscle and is most frequently found in the extremities
Av graft advantages?
Large surface area for cannulation Technically easy to cannulate Healing time is short Variety shapes and configurations Easy to implant, construct, and surgically repair
Av fistuala disadvantages?
Length of time to develop - generally 1-4 months Lower blood flows are sometimes necessary when the fistula is immature; results poor clearance Collateral circulation develops Isometric exercises may aid in development
What is monitored during treatment?
Machine alarms monitor the safe progression of the dialysis treatment. Alarms are divided into two categories. Blood related, and dialysate related
What is homeostasis?
Maintaining a stable internal environment
Osmosis
Movement of fluid from a lower concentration to a higher concentration
Diffussion
Movement of solutes from an area of higher concentration to an area of lower concentration.
Why should the needles sites be rotated?
Needle sites should be rotated to prevent weakening of the vessel walls and to prevent the formation of aneurysms and scar tissue. Sites should also be rotated to allow time for the previously punctured areas to heal
Thrombosis
No blood flow in the vascular access; blood inside the access is clotted
What is OLC? - On Line Clearance?
OLC measures the removal of waste from the bloodstream during a single dialysis treatment by measuring the rate of sodium removal.
When is it known that a patient has developed sensitivity to a dialyzer?
Patients develop mild to severe reactions in some cases, usually seen the first half hour of treatment. Sneezing, itching, pain at the access site, chest pain, rashing, hives, fever, all may be symptoms of dialyzer membrane allergy, or allergy to the sterilant used in the manufacturing process
When dialyzing a patient, what position should the dialyzer be in during hemodialysis?
Place the dialyzer arterial end up during the treatment.
Formula to determine fluid gain?
Pre wt - Last post wt
Formula to determine available weight?
Pre-weight - EDW
How is cramping treated?
Pressure against cramping muscle. DO NOT MASSAGE
How often is total chlorine tested?
Prior to the initiation of treatment in the morning and every 4 hours.
Which of the functions of healthy kidneys are replaced by dialysis?
Removal of waste products, and Regulation of fluid balance
What is the function of renin?
Renin is a hormone produced by the kidneys with important effects on the regulation of blood pressure, and on sodium and potassium balance
Hypertonic solution causes RBC's to do what?
Shrink
The most important electrolytes to consider in uremic patients are:
Sodium (Na+) Potassium (K+) Calcium (Ca++) Magnesium (Mg++)
Hypotonic solution causes RBC's to do what?
Swell
How do you test for a small blood leak?
Testing for a small blood leak consists of dipping a FMS approved blood leak test strip into dialysate obtained from the outflow (arterial/red) dialysate port. The blood leak test strip will change color if it is positive for blood. Do not return blood if the test is positive or if there are visible signs of blood in the dialysate.
How is dialysis delivered?
The Hemodialysis Machine is the Delivery System. The machine has two sub-systems. • Blood delivery system circulates the patient's blood • Dialysate delivery Mixes & circulates dialysate
What are the compartments of the dialyzer and what separates them?
The blood compartment is separated from the dialysate compartment by a semi-permeable membrane. The blood and dialysate do not mix together.
What should be checked on a dialyzer before machine set up?
The dialyzer should be checked for sterility (the dialyzer should either be intact in the original packaging or if out of the package should have all open ports capped), any structural damage and be the size and brand that was ordered by the doctor.
Why must the kidney activate Vitamin D?
The kidney converts Vitamin D to Calcitriol, its activated form. This activated form of Vitamin D helps to maintain good bone health by helping absorb calcium from foods eaten
Ultrafiltration
The use of pressure across a semi permeable membrane
What's TCD?
Theoretical conductivity (what the conductivity suppose to be +-5)
What does a steady decline in KECN test results signify?
There may be a need for more heparin. If the heparin dose is not adequate, the fibers of the dialyzer may be clotting off causing decrease in clearance
What is an adverse event?
This is a patient event reporting system. Any time there is a failure to follow established clinical procedure or a treatment prescription or when a serious or unexpected equipment event occurs at an outpatient, in-patient or home program, an adverse event occurs.
What is the "mean KECN"?
This is the average of all tests performed during On-Line Clearance
What is TMP?
Transmembrane pressure is the pressure difference across the dialyzer membrane. It reflects the total pressure across the membrane used to achieve the desired fluid loss
Av fistula advantgates?
Uses the patient's own vessels Length of time to Requires one anastomosis Isometric exercises may aid in development Longer life span Lower Decreased rate of complications Collateral circulation develops
-stenosis
abnormal narrowing of a blood vessel
retrograde
against the flow
What is Sodium Variation?
also called sodium modeling is a physician-ordered intervention to help prevent hypotension during dialysis treatment. There are three preprogrammed "profiles" that can be ordered by the physician based on several different comorbidities
The most likely cause of contamination of the extracorporeal circuit are ____________________ in the prime bucket with _________________ end caps.
bloodlines, open caps
uremia
build up of waste
Angia
chest pain
List signs and symptoms of vascular access infection?
chills, fever, drainage and pain, redness, swelling and warmth at the site
How often should staff clean the dialysis machine with acid?
daily
Dyspnea
difficulty breathing
disequilibrium syndrome
fluid imbalance between blood and brain tissue
Near misses, are sometimes referred to as _________________because they help diagnose a ________________ and reduce __________________________________>
good catches, system problem, and reduce patient injury
Excessive fluid removal during dialysis, combined with the patient's taking an antihypertensive medication may result in the patient having:
hypotension
What's anemia?
lack of RBC's
Safe range for total chlorine is
less than 0.10 ppm (0.00-0.09)
Name four ways dialysate is checked to ensure that it is safe?
pH, conductivity, monitoring the machine temperature, and a negative residual chlorine (bleach) after routine (weekly) machine disinfection and before the first treatment after the disinfection
Exsanguination
severe loss of blood
What electrolytes are found in the dialysate?
sodium (Na+) potassium (K+) calcium (Ca++) magnesium (Mg++) chloride (Cl-)
Erythropoietin
stimulates the bone marrow to produce red blood cells (RBSc).
hemolysis
the rupture or destruction of red blood cells.
Dialysate is composed of
treated water, acid solution, and bicarbonate solution
Use of a diasafe filter allows the production of?
ultrapure dialysate
anterograde
with the flow
What are three types of solutions?
• Hypotonic-containing less particles • Isotonic-containing equal particles • Hypertonic-containing more particles
