Fresenius Exam With Complete Solutions

What is a pre-dialysis evaluation? 1) Review of the patient's health. 2) Compares current health status to previous evaluations. Why is pre-dialysis evaluations needed? 1) To determine if the patient is stable to receive treatment. 2) Determine if there has been a change in health status. 3) Provides a baseline date to plan for a safe treatment. Describe Universal precautions Steps we take with all patient contact to decrease the risk of spreading infection to protect our patient and ourselves. What are the 3 C's? 1) Condition (objective) 2) Complaints (subjective) 3) Changes (objective) What should you look for with: Ambulation Gait changes, use of assistive devices, ROM, energy level. What should you look for with: Mental status and mood A&O x 3, any changes in usual mood (Alert and orientation) Person, place, time (situation) A&Ox4 What should you look for with: Skin Color, integrity, temperature, edema What should you look for with: Vital signs Weight, BP, HR, respiration's, temperature What is EDW? Estimated Dry weight A patient's wt with excess fluid removed When is a RN required to assess a pre-treatment wt? If the patient pre-treatment wt is 4 kg above EDW. What does a blood pressure measure? Measurement of the pressure of force of blood against the walls of the arteries. When do you report a blood pressure to the RN? SBP 100 or 180 DBP 100 When do you report a heart rate to a RN? New onset of HR 60 or 100 or a irregular beat When do you report a respiratory rate to the Rn? A respiratory rate of 24 breaths per minute True or False Does a dialysis patient maintain an average temperature? False! When do you report a temperature to the RN? Temperature 96 & or = to 100 degrees Name some important complaints you need to report to the RN? (10) 1) Dizziness 2) Chest pain 3) SOB (shortness of breath) 4) Any new complaints 5) A visit to the ER or a hospital stay 6) Weakness 7) Numbness or tinglinng 8) Fever or chills 9) Depression/sadness 10) Pain What changes do you report to the RN? New medications or visit to ER or hospital stay. What are the ABC's of the patients assessment? A) Access B) Breathing C) Cardiac What to look for with: Access Bruises, redness, drainage, swelling, bruit, thrill, pain, bleeding What to look for with: Breathing Rate, rhythm, quality, SOB, breath sounds What to look for with: Cardiac Skin color and turgor, heart sounds, pulse rate, rhythm & quality, edema, pain, SOB Why do patients expreience crackles (rales) breath sounds? Indicates fluid or congestion in lungs Name some reasons for an abnormal heart rate? Can indicate chemical imbalances or adverse effects from medications. Names some places fluid can get trapped? (Edema) Abdomen, lungs, feet, legs, hands,and face What are the ranges for pitting edema? 1-4 cm What do you do when you have a red light as a complaint? Do not start the treatment until the RN has done a full assessment on the patient. Dialysis Prescription and Pre-treatment safety checks: Name what verifies the correct patient's dialysis prescription? (11) 1) patient Identity 2) prescribed dialyzer 3) prescribed dialysate 4) special attention orders 5) SVS or UF profiling 6) prescribed heparin dose 7) OLC volume/test entered 8) prescribed dialysate rate 9) prescribed base sodium 10) prescribed bicarbonate 11) prescribed needle size Name important information programmed into the machine. (6) 1) Prescribed treatment time 2) UF goal entered correctly 3) Prescribed BFR 4) Prescribed DFR 5) OLC volume 6) Na modeling or UF profile Name the final dialysis machine safety checks. (5) 1) Dialysate temperature 2) Dialysate pH & conductivity 3) NS doubled clamped 4) Alarm & pressure holding test passed 5) Final check on blood circuit What is a priority and major reason why we monitor our patients? Patient safety As fluid shifts during dialysis what changes can occur? Blood pressure, fluid and electrolyte shifts. Who is responsible for monitoring patients? Everyone! The PCT must take what action when he or she identifies a potential problem? Immeddiate The RN must respond to what from patients and the PCT? Complaints or PCT notifications to assess the patient Why does a pateint's face and vascular access need to be visible at all times? (3) 1) It is a CMS requirement 2) Identify any changes in the patient's awareness 3) A covered access can result in major blood loss What are "Red Flags" to report to the RN? (5) 1) Severe hypertesnion (SBP 200) 2) Severe hypotension (SBP 80) 3) New onset of pulse 60 or 100 4) Irregular heart rate 5) Temperature or = to 100 degress What should the RN do when notified about "red Flags" 1) Assess the patient 2) Provide intervention 3) Report to the physician based on clinical judgment Name 4 non-verbal behaviors that may indicate a change in the patient status or discomfort: 1) Restlessness 2) Grimacing 3) Excessive yawning 4) Is patient alert, drowsy,sleepy Name 5 changes you should educate your patient to report immediately? 1) Discomfort at needle site 2) Muscle cramps 3) Headaches, dizziness, blurred vision 4) Nausea, vomiting 5) Fever, chills, chest pain, and SOB Name 4 machine reading we verify at every safety check? 1) BFR 2) DFR 3) AP (not more than-250) 4) VP (not more that 1/2 the bfr rate) Describe what the arterial pressure reading reflect? Refers to the pressure in the system from the patient;s vascular access to the blood pump. What are the potential compliactions of a high arterial pressure? (2) Inadequate dialysis and hemolysis Name 5 reasons for a high arterial pressure? 1) A kink in the arterial line 2) Poor cardiac status 3) Blood pump speed to much for vascular access 4) High hematocrit / increase blood viscosity 5) High BFR through a small needle gauge What can a low arterial pressure indicate? 1) A line separation 2) Air 3) A decrease blood pump speed 4) A wet transducer Describe what the venous pressure reading reflects? The pressure in the circuit after the dialyzer and before it re-enter the patient. Name 5 causes for low venous pressure? 1) Blood line separation 2) Needle dislodgement 3) Decrease BFR 4) Clotting before the monitoring site 5) Wet transducer What can cause high venous pressure? (5) 1) occlusion in the lines between the monitoring site and venous needle, 2) poor position 3) an infiltration of venous needle 4) poor CVC function 5) clotting in the access or dialyzer What is the most important function of the dialysis treatment? Fluid removal How can fluid removal be monitored? Critline monitor or CLM Describe the 3 profiles that the CLM provides? 1) Profile A 2) Profile B 3) Profile C What does profile A look like? Profile shows a flat or a positive slope indicating UF and plasma refilling were equivalent during treatment. -An increase in the UFR may be appropriate What does profile B look like? Profile shows a gradual slope indicating the best compromised between a high UFR and prevention of symptoms during treatment What does profile C look like? Profile-shows a steep slope indicating a rapid decrease in blood volume and the patient is more likely to experience complications and intervention is required. What does KT/V mean K= Clearance T= Time V= Volume What is the goal that FMC uses to calculate adequacy by KT/V 1.4 Describe the AMP lights meaning? Red The machine is in alarm mode Describe the Amp light meaning? Yellow means take action, the treatment will not meet our goal of 1.4 spKt/V Describe the Amp light meaning? Green means the patient will meet our goal of 1.4 spKt/V or above Monitoring the ECC includes (10) 1) The entire circuit is visible 2) Lines allow the patient position to change 3) All connections are correct & secure 4 )Lines secure in machine guides 5 )venous line in venous clamp 6) Chambers are filled adequately 7) NS is double clamped and contains at least 300 ml's 8) Hansen's are correctly connected to the dialyzer 9) Transducer are dry and unclamped 10) Heparin is infusing at the prescribed rate 30 minute checks include 1) vital signs 2) vascular access 3) machine checks (if the patient becomes unstable this must be done evey 5 minutes until the patient becomes stable) Name the safety check information that is documeted in Chairside: (7) 1) vascular access is secure, visible, no bleeding or infiltration 2) B/P and pulse 3) BFR and DFR 4) AP and VP 5) UF rate and UF removed 6) rate of heparin infusion 7) Most recent KCEN and Amp light status Effective documentation should be? (7) 1) Objective 2)legible 3) specific 4) unaltered 5) consistent 6) chronological Name who is responsible to document in the patient's medical record? (6) 1) Nephrologist 2) RN 3) LPN 4) PCT/CCHT 5) RD 6) SW Name 3 locations where we provide documentation? 1) Chairside 2) eCube 3) Paper chart Why is documentation important? Communication, evidence of care rendered & patient response, the chart is a legal document. Diffusion is? The movement of solutes from and arena of HIGH solute concentration to area of LOW solute concentration across a semi permeable membrane. Osmosis is? The movement of water from an area of LOW solute concentration to an area of HIGH solute concentration. Filtration is? Movement of a solution through a semipermeable membrane. Ultrafiltration is? filtration using pressure. What are the goals of hemodialysis? (3) 1) removal of waste products 2) regulation of fluid balance 3) correction of electrolyte and acid/base imbalance Identify seven components of the hemodialysis prescription 1) treatment time 2) type of dialyzer 3) blood flow rate 4) dialysate flow rate 5) dialysate composition 6) needle size 7 anticoagulation Identify four components of the extra-corporeal circuit. 1) Arterial line 2) Venous line 3) Needles 4) Dialyzer Biocompatibility is? a term to describe a dialyzer membrane that is more like the human body and less likey to cause an immune response. Dialyzers with more surface area allows? More removal of solutes. Transmembranes pressure affects? Fluid removal Pressure on the blood side is positive Pressure on the dialysate side is negative Define countercurrent flow? Blood flows one way while the dialysate flows the opposite wasy. What is the advantages of countecurrent? Allows more net diffusion. Dialyzer clearance is the amount of what? Blood cleared of a given solute in one minute at agiven BFR and DFR Identify five factors that affect dialyzer clearance? 1) BFR 2) DFR 3) Dialyzer characteristics 4) Treatment time and frequency 5) Anticoagulation Dialysate is composed of 1) Treated water 2) acidified concentrate (acid) 3) bicarbonate concentrate Is dialysate clean or sterile Clean identify five electrolytes in the acid concentrate? 1) sodium 2) potassium 3) calcium 4) magnesium 5) chloride Kidney failure causes what to build up and leads to what? 1) acid 2) metabolic acidosis What componet of the dialysate treats metabolic acidosis? bicarbonate Identify the two sources of the bicarbonate in final dialysate? 1) bicarbonate concentrate 2) Acetate in the acide concentration Two electrolytes that are part of the doctor's dialysate and are highlighted on the acid concentrate label are? Potassium and calicum Alarms to monitor the dialysate to ensure it is safe to use: 1) conductivity alarm 2) temperature alarm What is conductivity? a measure of the ability of a solution to conduct an electrical charge Is verification of the conducitivy and pH required? Yes, before initiating treatment using a independent meter What verifies the conductivity and and pH? (2) 1) Phoenix meter 2) Precision PH control paper When does the phoenix meter need to be calibrated and verified? At the start of every treatment day. What is an acceptable pH range on a phoenix meter? 6.9-7.6 What is an acceptable pH range when using a pH test strip? 7.0-7.4 What are the two autoflow setting? 1) A 1.5 2) A 2.0 What is the purpose of a dialysafe filter? It removes endotoxins and other impurities from dialysate. For a prime dialyzer that has been set up for greater than 2 hours what MUST be done prior to initiating the treatment? Recirculating using ultrafiltration for 5 minutes. Three signs of excessive heparinization? 1) Bleeding at the needle insertion site during tx 2) Bleeding 20 mins from access post treatment 3) Excessive bruising Heparin is given 5 minutes before treatment is started to allow for what? Systemic anticoagulation Heparin loading (bolus) dose is given in what port? Venous When opening a new vial of heparin what three things are recorded on the label? 1) Date 2) Time 3) Initials When is heparin held? What can you use instead? 1) If the patient fell or hit their head 2) if the patient has a headache 3) if the patient is scheduled for surgery 4) if patient C/O bleeding N/S flushes is one method to use during heparin free dialysis to prevent clotting What is adequacy a measurement of? a measurement of how the dialysis is working to clear waste products from the patient's blood Inadequate hemodialysis results in: (3) 1) decreased sense of well being 2) increased hospitalizations 3) increased risk of death Two adequacy measurements are 1) URR (urea reduction ratio) 2) Kt/V This is used to calculate Urea Kinetic Modeling? Kt/V What lab is used to measure adequacy? Pre and Post Bun Four causes of inadequate dialysis? 1) clotted dialyzer 2) lower than prescribed BFR 3) Shorter than prescribed treatment time 4) significant recirulation Urea is present in all three body fluid spaces, name these fluid spaces? 1) Intracellular 2) Interstitial 3) Intravascular During hemodialysis urea is removed from only one body fluid space which is the? Intravascular space