Nursing Measures in Hemodialysis and Peritoneal Dialysis PDF

SKILLS 118 NURSING MEASURES IN HEMODIALYSIS HEMODIALYSIS AND 1. Observe carefully for breaks or kinks in membranes to prev...

SKILLS 118 NURSING MEASURES IN HEMODIALYSIS HEMODIALYSIS AND 1. Observe carefully for breaks or kinks in membranes to prevent hemorrhage. PERITONEAL DIALYSIS 2. Monitor the chemical composition of the dialysate solution, the fluid rate and pressure, and blood clotting time (anticoagulants are administered WHAT IS DIALYSIS? throughout hemodialysis). Is the process of osmosis and diffusion used to 3. Provide shunt care: reestablish fluid and electrolyte balance - Keep the area clean, dry and sterile To remove toxic substances and metabolic wastes - Observe the internal shunt for patency. If it is working, you can feel a thrill on palpation or DIFFUSION hear a bruit with a stethoscope; if the shunt is Is the passage of ions from an area of high discolored, patency is questionable. concentration across a semipermeable membrane to an - Immediately report clotting to the physician. area of lower concentration. - Avoid trauma to the extremity with the shunt (no blood pressure measurement, intramuscular or intravenous medications, or blood drawn). OSMOSIS - Have clamps available to prevent Is the passage of water molecules across a 4. Provide comfort for the client. semipermeable membrane from a less concentrated solution to a more concentrated one. PERITONEAL DIALYSIS PERITONEAL DIALYSIS Dialysis fluid enters the peritoneum. The fluid remains in contact with the peritoneum for 20 A commercially prepared sterile dialysate, an to 30 minutes whilE dialysis occurs. electrolyte solution, flows by gravity through a catheter Post-dialysis waste products drain from the peritoneal inserted through the abdominal wall into the peritoneal cavity. cavity. 1. Ask the client to urinate before you insert the After the solution has remained in the peritoneal cavity catheter into the peritoneum, to prevent bladder for the prescribed time, the dialysate is removed. The puncture. physician will order this process repeated until the 2. Warm the bottles of dialysate in warm water. client’s fluid and electrolytes fall within acceptable limits. 3. Permit 2 liters of dialysate to flow unrestricted into the peritoneal cavity (this should take about 10 PERITONEUM minutes) Acts as the semipermeable membrane for osmosis 4. Allow fluid to remain in the cavity for the time and diffusion. ordered by the physician (about 20 to 30 minutes) This is a recent variation of peritoneal dialysis. It 5. Reverse the bottles; allow fluid to drain from the involves infusing 500 to 1,000 ml of personalized peritoneal cavity unrestricted (about 20 to 30 dialysate through a peritoneal catheter, clamping the minutes). Facilitate drainage by changing the catheter with the empty bag still attached, rolling the bag client’s position or massaging thE abdomen. up, and placing it in a waistband, with the client then 6. Keep accurate intake and output records related to going about his usual activities. the amount of dialysis fluid entering the peritoneal Every 4 hours the client drains the fluid from his cavity and the amount in the drainage. peritoneal cavity into the empty bag of dialysate, and Important: Remove all dialysis fluid. repeats the infusion. NURSING BEHAVIORS: MAJOR COMPLICATIONS OF CAPD 1. Peritonitis BEFORE DIALYSIS: 2. Fluid and Electrolyte Imbalance 1. Explain the procedure 3. Dehydration Rationale: Explanations help reduce the client’s 4. Catheter Sepsis anxiety 5. Abdominal Pain and tenderness 2. Weigh the client, using a bed scale, and measure 6. Organ Trauma the client’s vital signs. 7. Hemorrhage Rationale: This information establishes a baseline for future comparison HEMODIALYSIS 3. Place the client in a comfortable supine or semi- reclining position. Uses a machine that contains semi-permeable Rationale: The client must remain in one membranes in a dialysate solution prepared according position for 6 to 8 hours. to the client’s electrolyte values. Diffusion and ultrafiltration occur after the client’s DURING DIALYSIS: heparinized arterial blood runs through the machine and returns through one of the client’s veins. This process 1. Provide emotional reassurance to the client and continues until the client’s fluid and electrolyte values fall family throughout the procedure. within the limits set by the physician. Rationale: This will assist in decreasing their anxiety. 2. During peritoneal dialysis, carefully provide passive range-of-motion exercises to all the limbs of a client, Transcribed by: Taño BSN 4-J 1  and during hemodialysis, to every limb except the arm or leg with the shunt. THE HEALTHCARE Rationale: This will prevent muscle stiffness and soreness. With hemodialysis, the arm or leg with WORKERS’ HANDS AND the shunt is left unexercised to avoid dislodging the catheter. HANDWASHING 3. Maintain aseptic technique in peritoneal dialysis, Healthcare workers’ hands are the most common with care of the peritoneal catheter and the area vehicle for the transmission of around it, and in hemodialysis, with all tubing healthcare-associated pathogens from patient and within connections and at the shunt site. the healthcare environment. Rationale: Aseptic technique helps prevent HAND HYGIENE is the leading measure for infection, a potentially serious complication. preventing the spread of antimicrobial 4. Monitor the client’s vital signs every 15 minutes resistance and reducing healthcare-associated (blood pressure will go down as the body loses infections fluid). Rationale: Monitoring the vital signs helps WASTE MANAGEMENT determine whether the client is losing fluid too  General/Non Infectious/Dry- BLACK rapidly; early detection can prevent  General/Non Infectious/Wet- GREEN complications, such as infection, arrhythmias  Infectious/Pathological- YELLOW and shock.  Sharps and pressurized containers- RED  Radioactive Waste- ORANGE AFTER DIALYSIS:  For chemical waste including those with heavy 1. Monitor the client’s pulse rate and blood pressure metals- YELLOW WITH BLACK BAND every 15 minutes until the client becomes stable, then every 4 hours. BLACK CONTAINER Rationale: Arrhythmias pose a threat. A client Used paper, newspapers who loses fluid too rapidly will go into Plastic hypovolemic shock. Candy wrappers 2. Monitor the client’s weight daily and temperature Empty bottled water every 4 hours. Tissues, or other biological materials that are known to Rationale: This identifies when the client will be free from contamination need dialysis again, and to monitor infection as it poses a possible complication. GREEN CONTAINER Kitchen left over foods INFECTION CONTROL AND Fruits and vegetables peelings Used cooking oil PERSONAL PROTECTIVE Rotten fruits and vegetables Fish entrails, scale and fins EQUIPMENT (PPE) RED CONTAINER PATIENT SAFETY Sharps and pressurized containers  Patient safety is the absence of preventable harm to a patient during the process of health careand YELLOW CONTAINER reduction of risk of unnecessary harm associated used dressing, bandages (for wounds) with health care to an acceptable minimum (WHO, cotton balls 2021). materials (like tissue paper) with blood, secretions,  Is a practical, evidence-based approach which and other exudates prevents patients and health workers from being Disposable materials used for the collection of blood harmed by avoidable infection and as a result of and body fluids (including diapers, antimicrobial resistance (WHO, 2021). sanitary packs, and incontinence pads) Tubing’s INFECTION CONTROL NURSE Used syringes  Implements and coordinates surveillance, Foley catheters, F. suction Cath/tubing, and gloves. prevention and control activities  Responsible for the day to day functions of the ICC ORANGE CONTAINER  Prepares the yearly work plan for review by the ICC SOLID waste containing traces of radioactivity is in the and administration form of syringes, needles, cotton  Conducts outbreak investigation swabs, vials, contaminated gloves and absorbent  Evaluates materials and products relevant to materials; active wastes infection control  Trains and orients personnel YELLOW WITH BLACK CONTAINER  Conducts research Mercury  Ensures compliance with local and national - Thermometers, sphygmomanometer regulations - Cantor tubes, esophageal dilators  Coordinates with public health and with other - Mercury switches, fluorescent lamps facilities where appropriate Cadmium  Provides expert consultative advice to staff health - Dry cell batteries and other appropriate program matters relating to Lead transmission of infections - Radiation shielding Transcribed by: Taño BSN 4-J 2  ENTERING AND EXITING ISOLATION ROOMS: NEEDLESTICK INJURY 1. Before entering the isolation area, remove practice If you sustain a sharp injury, the most important thing outerwear (e.g., laboratory coat) and any to do is to make sure you FILE A INCIDENT REPORT. equipment (e.g., stethoscope, scissors, thermometer, watch, cell phone) and leave outside CRITICAL INFORMATION TO COLLECT the isolation unit/anteroom. 2. Gather any necessary supplies and medications FOR REPORTING PURPOSE INCLUDES before putting on PPE. THE FOLLOWING DETAILS: 3. Perform hand hygiene and then put on booties, Date and time of exposure gowns, and gloves before entering the isolation Procedures involved in the injury room Exposure specifics 4. Attend to the patient in isolation as needed. DO Source patient specifics (if known) NOT bring treatment sheets, pens, or electronic Exposed person specifics devices such as laptops, cell phones, or tablets into Counseling, post-exposure management, and follow- the isolation room. up. 5. Clean and disinfect any equipment used while caring for the patient INFECTION CONTROL MEASURES 6. Before leaving the isolation room, remove PPE. Clean and disinfect no disposable PPE (e.g., eye protection). Place used disposable PPE in the trash ENVIRONMENTAL CLEANING AND container lined with a biohazard bag in the isolation DISINFECTION PROTOCOL: room. DO NOT SAVE DISPOSABLE PPE FOR 1. Have all material safety data sheets or product REUSE. Avoid contact with external portions of the safety data sheets for cleaning and disinfection door when exiting the isolation room. Materials are available. Follow instructions for 7. Perform hand hygiene and then disinfect any proper mixing, disposal, and PPE (e.g., gloves, eye surfaces (e.g., doorknobs) that may have Protection). As able, ensure the area is well- accidentally been contaminated when the room was ventilated. exited. Make any needed chart entries. Wash 2. Exam rooms and cages should be cleaned and hands again before leaving the anteroom (as disinfected immediately following use. Place applicable). signage at the room entry that it should not be used until cleaning and disinfection is completed. 3. As applicable, remove all bedding and organic DONNING AND DOFFING material (e.g., feces, feed, hair, linens, bandage, or other materials) and dispose in a designated waste OF PPE bin. Gloves should be worn during this procedure. 4. “Dry”-clean surfaces (e.g., sweeping, wiping with a PURPOSE: disposable microfiber cloth) to remove loose To shield the health care provider from chemical, organic material. physical, biological, radiologic hazards that may exist 5. “Wet”-clean surfaces with warm water and when caring for contaminated patients. detergent. Scrubbing surfaces is often necessary to remove feces or bodily fluids, biofilms, and stubborn organic debris, especially in animal CATEGORIES OF housing areas. 6. Rinse with clean water. For all rinsing and product PROTECTIVE EQUIPMENT application procedures, care must be exercised to avoid overspray. High-pressure washing should be CATEGORY A: avoided. Higher pressures can help remove Self contained breathing apparatus (SCBA) and stubborn organic debris but may also force debris vapor-tight chemical resistant suit, and organisms into crevices or porous materials, gloves, and boots. from which they can later emerge. CATEGORY B: 7. Allow the area to dry or manually do so. If excess water remains, subsequently applied disinfectants High level of respiratory protection (SCBA) but lesser may be diluted to the point of inefficacy. skin and eye protection;chemical-resistant suit. 8. Apply disinfectant solution at the indicated concentration and ensure the appropriate contact time. NURSING TRIAGE 9. Allow the treated area to dry as much as possible before reintroducing animals or reusing the area. TRIAGE 10. In known contaminated or high-risk areas, a second  comes from the French word tier, meaning “to sort”. application of a disinfectant with wide spectrum  It is used to sort patients into groups based on the (e.g., accelerated hydrogen peroxide product) severity of their health problems and the immediacy should be considered as a final decontamination with which these problems step. Ensure appropriate contact time, rinse with  Must be treated. clean water, and allow the treated area to dry, as  This includes the identification of an appropriate stated above. hospital destination and method of transport and is based on the patient's age and medical problem or PROTOCOL FOR ENTERING AND EXITING type of trauma, an objective measure of the acuity of the condition, and the distance from an AN ISOLATION AREA Emergency Department. Transcribed by: Taño BSN 4-J 3 OBJECTIVES OF TRIAGE d. Cervical spine injury Multisystem trauma e. Altered level of consciousness (LOC) Head injuries to the eyes Chemical exposure (unconsciousness) f. Eclampsia Severe asthma Severe headache Severe trauma Chest pain TRIAGE LEVEL II: EMERGENT Pain in patients Any pain greater older than age 50 than 7 on a scale of 10 These are conditions requiring nursing assessment and physician assessment within 15 minutes of arrival. Lethargy or agitation Back pain Vomiting and diarrhea with Any sexual assault TRIAGE LEVEL III: URGENT dehydration These are conditions requiring nursing and physician Conscious GI bleed with assessment within 30 minutes of arrival overdose unstable vital signs Conditions include: Fever in infants younger Any neonate age 7 a) Alert head injury with vomiting than 3 months days or younger b) Mild to moderate asthma Severe allergic Stroke with deficit c) Moderate trauma reaction d) Abuse or neglect  The triage levels assist the nurse in precisely e) GI bleed with stable vital signs determining the needs of the patient and the f) History of seizure, alert on arrival urgency for treatment.  Triage is classifying clients according to their need TRIAGE LEVEL IV: LESS URGENT for care and establishing priorities of care; the kind These are conditions requiring nursing and physician of illness, the severity of the problem and the assessment within 1 hour. resources available. Conditions include:  Alert head injury without vomiting HISTORICAL PERSPECTIVE: TRIAGE  Minor trauma  Therefore, French studies and the origin of triage  Vomiting and diarrhea in patient older than age 2 shown in domestic and foreign published works without evidence of dehydration have been investigated and its significance  Earache reaffirmed.  Minor allergic reaction  The etymology of the word “triage” means “to break  Corneal foreign body into three pieces.” It was suggested by a literature  Chronic back pain review that the rise of Napoleon led to military tactical changes and that the prototype of triage TRIAGE LEVEL V: NON-URGENT arose from experience gained in the difficult These are conditions requiring nursing and physician campaign in Egypt and Syria. assessment within 2 hours.  Subsequently, triage was refined by Napoleon's Conditions include: military surgeon, D. J. Larrey, who created the a. Minor trauma, not acute ambulance transport system. b. Sore throat c. Minor symptoms BARON DOMINIQUE JEAN LARREY d. Chronic abdominal pain  A French military chief surgeon in Napoleon Bonaparte's imperial guard, developed asystem based on the need to evaluate and categorize EMERGENCY DEPARTMENT wounded soldiers quickly during battle TRIAGE SYSTEM WEINERMAN ET AL- 1964 - may be according to individual hospital protocol.  The triage system was first implemented in hospitals. Published a systematic interpretation of EMERGENT (RED): PRIORITY 1 (HIGHEST) civilian emergency departments using triage This classification is given to clients who have life- threatening injuries and need immediate attention and CATEGORIES continuous evaluation yet have a high probability of survival once stabilized.  Emergent – Highest priority  Urgent – have serious health problems but are URGENT (YELLOW): PRIORITY 2 not life-threatening; This classification is given to clients who require  Non-urgent – those who have episodic illnesses treatment and whose injuries have complications that without increased morbidity are not life-threatening.  “Fast-track”- requires simple first aid or basic primary care. NON-URGENT (GREEN): PRIORITY 3 This classification is given to clients with local injuries STANDARDIZED TRIAGE SYSTEM (5- who do not have immediate complications and who can LEVEL TRIAGE SYSTEM) wait for several hours for medical treatment. TRIAGE LEVEL I: RESUSCITATION EMERGENCY SEVERITY INDEX (ESI) These are conditions requiring immediate nursing and The Emergency Severity Index (ESI) is a five-level physician assessment. Any delay in the treatment is emergency department (ED) triage algorithm that potentially life or limb-threatening. Conditions include: provides clinically relevant stratification of patients into a. Airway compromise five groups from 1 (most urgent) to 5 (least urgent) on b. Cardiac arrest the basis of acuity and resource needs. c. Severe shock Transcribed by: Taño BSN 4-J 4 LEVEL DESCRIPTION EXAMPLE SECONDARY ASSESSMENT 1 Immediate, life-saving Cardiac arrest The secondary assessment is a brief but thorough, intervention required Massive systematic assessment designed to identify all injuries. without delay bleeding Steps: (EFFGH) 2 High risk of Cardiac-related E- Expose/ environmental control deterioration,or signs of a chest pain F- Full set of vital signs time-critical problem Asthma attack F- Five interventions: 3 Stable, with multiple Abdominal types of resources 1. Pulse oximetry Pain High fever needed to investigate or 2. Indwelling urinary catheter with cough treat (such as lab 3. Gastric tube tests plus X-ray imaging) 4. Laboratory studies 5. Pregnancy test (if applicable) 4 Stable, with only one Simple F- Facilitate family presence type of resource laceration G-Give comfort measures anticipated (such as Pain on H-History only an X-ray, or only urination sutures) 1. Obtain pre-hospital information from emergency 5 Stable, with no Rash personnel, patient, family or bystanders. resources anticipated Prescription except oral or topical refill M- mechanism of injury medications, or prescriptions I- Injuries sustained or suspected V- Vital signs EMERGENCY ASSESSMENT T- treatment  A systematic approach to the assessment of an 2. If the patient is conscious, it is essential to ask him emergency patient is essential. what happened.  The most dramatic injury is not the most serious. 3. Obtain past medical history from the patient or a  The primary and secondary assessment provide family member or friend. the emergency nurse with a methodical approach to 4. Head-to- toe Assessment help identify and prioritize patient needs. 5. Focused assessment A (AIRWAY) DIFFERENT METHODS OF TRIAGE Does the patient have an open airway?  START- Simple Triage and Rapid Treatment a. Is the patient able to speak?  SALT- sort, Assess, Life-saving interventions, and b. Check for airway obstructions such as loose teeth, Treatment/Transport foreign objects, bleeding, vomits or other secretions.  ATS- Australasian Triage Scale NOTE: Immediately treat anything that compromises the airway.  CTAS- Canadian Triage and Acuity Scale  MTS-Manchester Triage System B (BREATHING)  ESI- Emergency Severity Index Is the patient breathing?  Assess for equal rise and fall of the chest (Check METHOD COMMONLY USED IN TRIAGE for bilateral breath sounds), respiratory rate and pattern, skin color, use of accessory muscles, START = Start Triage and Rapid Treatment integrity of the chest wall and position of the trachea) - is a triage method used by first responders to quickly NOTE: All major trauma patients require supplemental classify victims during a mass casualty incident(MCI) oxygen via a non-re-breather mask. based on the severity of their injury. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services. C (CIRCULATION) Is circulation in immediate jeopardy? PEDIATRIC TRIAGE a. Can you palpate the central pulse? What is the  Children are involved in mass casualty incidents. quality (strong, weak, slow, rapid)?  The over prioritizing of children will take valuable b. Is the skin warm and dry? resources away from more seriously injured adults. c. Is the skin color normal?  Triage systems based on adult physiology will not d. Obtain a blood pressure (in both arms if chest provide accurate triage. trauma is suspected). Pediatric modification for: START = JUMPSTART D (DISABILITY) Kids Are A Little Different  Assess level of consciousness and pupils (a more - Expect children to be part of a disaster complete neurologic survey will be completed in the - JumpStart- modified START for kids secondary survey). - Designed for children ages 1-8 y/o  Assess LOC using the AVPU scale: A- Is the patient alert? PEDIATRIC MODIFICATIONS - RPMs V- Does the respond to voice? P- Does the patient respond to painful stimuli? RESPIRATORY EFFORT U- The patient is unresponsive even to painful stimulus (not breathing)  Open the airway  If the patient starts breathing tag RED Transcribed by: Taño BSN 4-J 5  If apneic and no pulse tag BLACK  Hepatic – Serum Bilirubin  If apneic with pulse try 5 rescue breaths  If still apneic tag BLACK QUICK SOFA SCORE  If starts breathing tag RED  The Quick SOFA Score (quickSOFA or qSOFA) was introduced by the Sepsis-3 group in February Respirations < 15 or > 45 tag RED 2016 as a simplified version of the SOFA Score as Respirations 15-45 go to next step (Pulse) an initial way to identify patients at high risk for poor outcome with an infection. PULSE  The SIRS Criteria definitions of sepsis are being No distal pulse- tag RED replaced as they were found to possess too many Pulse poresent goto next step (Mental) limitations; the "current use of 2 or more SIRS criteria to identify sepsis was unanimously MENTAL STATUS considered by the task force to be unhelpful."  The SOFA simplifies the SOFA score drastically by (use AVPU) only including its 3 clinical criteria and by including  Alert, responds to verbal or respond to pain "any altered mentation" instead of requiring a GCS tag YELLOW