Monthly Archives: February 2018

MANAGEMENT OF HEMODIALYSIS VASCULAR ACCESS

MANAGEMENT OF HEMODIALYSIS VASCULAR ACCESS

SOME DEFINITIONS BEFORE TALKING ABOUT STEPS FOR MANAGEMENT OF HEMODIALYSIS VASCULAR ACCESS

  1. Arteriovenous Fistula (AVF) – is the result of a surgical creation of an anastomosis between an artery and a vein, which allows arterial blood to flow through the vein, causing venous engorgement, enlargement, and thickening of the venous wall. The arterial limb and anastomosis are never cannulated.
  2. Arteriovenous Graft (AVG) – is a biologic, semi biologic or synthetic (such as Gortex or Teflon or Polytetrafluorethylene -PTFE), implanted subcutaneous and interposed between an artery and a vein. Needles are inserted into the graft material in order to remove and return blood during hemodialysis.
  3. Central Venous Catheter (CVC) – is a device used on a long- term or short- term basis as circulatory access for hemodialysis. CVC is made of silicone rubber, rigid or semi-rigid material of a varying length and is radio-opaque. A double lumen catheter (Quinton Cath) is most commonly used. This catheter is placed in the internal or external jugular, subclavian or placed percutaneously in the femoral vein.
  4. Long-Term CVC (Permcath) – is indicated for patients in whom permanent AV access is no longer possible, or who are waiting for native AV fistula to mature/develop or who are waiting for the creation of permanent AV access. These catheters are usually placed in the internal jugular vein or the subclavian vein and a subcutaneous tunnel is created that allows the catheter to exit the chest wall. There is a dacron cuff on the catheter that will facilitate tissue growth into it to hold the catheter in place and provide a barrier to bacteria growth.

 

Hemodialysis

Hemodialysis, also spelled hemodialysis, commonly called kidney dialysis or simply dialysis, is a process of purifying the blood of a person whose kidneys
PROPER MANAGEMENT OF HEMODIALYSIS VASCULAR ACCESS

 

  1. To establish a safe procedure for accessing the patient’s circulatory system using AVF/AVG or CVC access for hemodialysis treatment.
  2. To provide effective management to optimize the hemodialysis delivery dose.

  1. Hemodialysis access shall only be used for hemodialysis treatment as described in this policy.
  2. The use of hemodialysis central venous catheters for other purpose is restricted to circumstances where there is no other alternative to access a vein.
MANAGEMENT OF HEMODIALYSIS VASCULAR ACCESS Procedures Responsible Person/s
Explain to the patient and family members the need for vascular surgery to create AVF or AVG; or a hemodialysis central venous catheter for hemodialysis treatment. Nephrologist
Complete a written order for creation of AVF or AVG or insertion of a temporary or permanent central venous catheter. Nephrologist
Contact the Vascular Surgeon and writes a consultation for vascular surgery intervention. Nephrologist
In the event of malfunction of AV access or clotted AVF, AVG or central venous catheters; the Nephrologist shall assess the patient and contact the Vascular Surgeon. Nephrologist

Vascular Surgeon

Insert temporary central venous catheter for hemodialysis in the ICU. In special cases, the nephrologist may insert the central venous catheter in the Dialysis Unit. Nephrologist
Insert the hemodialysis permanent central venous catheter (Permcath) in the Cardiac Catheterization Laboratory (CCL) or Operating Room Vascular Surgeon
Use aseptic technique to access; perform exit-site care and manipulation of the hemodialysis central venous catheter. Dialysis Registered

Nurse

Perform catheter care pre or post-hemodialysis treatment on the day of dialysis in the unit. Dialysis Registered

Nurse

For permanent AV access:

1.       Blood pressure or venipunctures are not performed on the AV access limb.

2.       Circular occlusive dressings are not applied on the AV access limb at all times.

3.       Patient is instructed not to wear restrictive clothing that impedes blood flow to the AV access limb

 

Dialysis Registered

Nurse

Give teaching to the patient to care of his/her AVF, AVG, or central venous catheter as follows:

1.  Assess the level of the patient’s knowledge of their hemodialysis access, which includes purpose, description, care, assessment and emergency care. Provide instruction as required, utilizing expertise and knowledge from all members of the renal multidisciplinary team.

2. Teach the patient the importance of good hygiene.

3. Instruct the patient/family member in the care of vascular access and to recognize the signs and symptoms of infection.

 

Dialysis Registered

Nurse

Refer to Patient Teaching Policy about Central Venous Catheter care and Care of AV Graft and AV Fistula. Dialysis Registered

Nurse

Advice the patient to contact the hospital immediately if he/she encounters problems with vascular access. The patient is given an emergency telephone number to contact the hemodialysis unit or the patient can go to the nearest hospital, emergency services. Dialysis Registered

Nurse

Nephrologist

Documents assessment, management and patient education of vascular access clearly and legibly on the Focus Charting Sheet. Dialysis Registered

Nurse

Nephrologist

Advice the patient to contact the hospital immediately if he/she encounters problems with vascular access. The patient is given an emergency telephone number to contact the hemodialysis unit or the patient can go to the nearest hospital, emergency services. Dialysis Registered

Nurse

Nephrologist

 

REFERENCE FOR MANAGEMENT OF HEMODIALYSIS VASCULAR ACCESS 

  1. Clinical Practice Guidelines for Vascular Access, National Kidney Foundation
  2. Handbook of Dialysis, John T. Daugirdas, Todd S. lng
  3. CBAHI 3’“ Edition Standards
  4. JClA 5″‘ Edition Standards

EMERGENCY MANAGEMENT OF HYPOGLYCEMIA

EMERGENCY MANAGEMENT OF HYPOGLYCEMIA

EMERGENCY MANAGEMENT OF HYPOGLYCEMIA

EMERGENCY MANAGEMENT OF HYPOGLYCEMIA

DEFINITION

Hypoglycemia – refers to a condition wherein the blood glucose falls less than 60 mg/dl or drops rapidly from a higher level with or without the presence of signs and symptoms.

Hypoglycemia

Hypoglycemia, also known as low blood sugar, is when blood sugar decreases to below normal levels. This may result in a variety of symptoms including clumsiness

PURPOSE OF EMERGENCY MANAGEMENT OF HYPOGLYCEMIA

  1. To ensure correct management of hypoglycemia.
  2. For early recognition of signs and symptoms of hypoglycemia and have a prompt and quick action to save patients lives.
Low Blood Glucose (Hypoglycemia) | NIDDK

Hypoglycemia, also called low blood glucose or low blood sugar, occurs when the level of glucose in your blood drops below normal. For many people with diabetes, that means a level of 70 milligrams per deciliter (mg/dL) or less. Your numbers might be different, so check with your health care provider to find out what level …

 

POLICY OF EMERGENCY MANAGEMENT OF HYPOGLYCEMIA

  1. All known diabetic patients must be checked for blood glucose on Doctors order and according to patients’ condition.
  2. Capillary blood glucose must be checked as soon as signs and symptoms of hypoglycemia identified.
  3. The physician must have a specific written order for the medication to be administered in the treatment of hypoglycemia.
Write order in the Doctor’s order sheet for medication to be administered for emergency management of hypoglycemia. Physician
Document all the pertinent information in a timely manner in the medical record. Physician
Check the blood glucose level as soon as the hypoglycemia is recognized and report to the treating physician and document. Registered Nurse
Assess patient’s condition, vital signs and report to the physician immediately. Registered Nurse
Carry out Doctor’s Order promptly and quickly to save patients life.  
Observe patients’ reaction and changes to each treatment given and document properly. Registered Nurse
Treat hypoglycemia promptly. and follow EMERGENCY MANAGEMENT OF HYPOGLYCEMIA PROTOCOL Registered Nurse

SEE ALSO

 

Drugs Used in Diabetes

Diabetes mellitus occurs because of a lack of insulin or resistance to its action. It is diagnosed by measuring fasting or random blood-glucose concentration (and occasionally by glucose tolerance test). Although there are many subtypes, the two principal classes of diabetes are type 1 diabetes and type 2 diabetes. Type …
Hypoglycemia Signs and Symptoms

He – Headache Is – Irritable / Sweating T – Tachycardia I – Irritability R – Restlessness E – Excessive Hunger D – Dizziness
INTRAVENOUS INSULIN ADMINISTRATION USING SYRINGE PUMP

  DEFINITION Insulin – is a hormone secreted by the pancreas that promotes glucose INTRAVENOUS INSULIN ADMINISTRATION utilization, protein synthesis, formation and storage of natural lipids. Continuous IV Infusion – is a method of administering IV medication to a patient at a constant rate through a …

 

INTRAVENOUS INSULIN ADMINISTRATION USING SYRINGE PUMP

 

DEFINITION

  1. Insulin – is a hormone secreted by the pancreas that promotes glucose
    INTRAVENOUS INSULIN ADMINISTRATION

    INTRAVENOUS INSULIN ADMINISTRATION

    utilization, protein synthesis, formation and storage of natural lipids.

  2. Continuous IV Infusion – is a method of administering IV medication to a patient at a constant rate through a syringe pump to maintain a stable level of the medication in the blood.

PURPOSE

  1. To standardize methods of intravenous insulin administration.
  2. To provide guidelines for monitoring patients receiving insulin infusion.
  3. To reduce the occurrence of possible complications.

 

INTRAVENOUS INSULIN ADMINISTRATION

PROCEDURES & RESPONSIBILITY

  1. Continuous insulin IV infusion shall have a written physician order, as well as a separate specific order for each rate, changed based on capillary blood sugar results.
  2. Regular insulin is the only insulin that can be given through IV.
  3. A patient who is on continuous IV insulin infusion should be kept under close observation.
  4. An infusion pump should be used for IV insulin infusion.
  5. Insulin infusion should be a separate IV site whenever possible.

 

Procedures Responsible Person/s
Write the order for the administration of insulin infusion and clearly document the specific order for each rate change based on the result of the capillary blood glucose. Physician
Document all the pertinent information in a timely manner in the medical record. Physician
Prepare the IV insulin infusion using the following solution:

50 ml Normal Saline containing 50 units Regular Insulin (1 unit/ml).

Registered Nurse
Baseline blood sugar by finger stick should be checked before starting an insulin infusion. Registered Nurse
A copy of physician order should be sent to the pharmacy (Unit Dose System). Registered Nurse

Pharmacy

Initiate and regulate the IV insulin infusion according to the doctors’ order. Registered Nurse
Document IV site condition, infusion setting and patient level of consciousness at the beginning of infusion and any additional information in the nurse’s notes. Registered Nurse
A patient on continuous IV infusion shall have a capillary blood glucose monitoring every 1-2 hourly, and if it remains stable may decrease to 4 hourly. Registered Nurse
Monitor the patient every 2 hours or as ordered by the doctor for the

following:

·         Level of consciousness

·         Signs and Symptoms of Hypoglycemia

·         Other pertinent parameters

Registered Nurse
Use professional judgment and ongoing assessment when caring for a patient who is on IV insulin infusion. Registered Nurse
Notify the attending physician of any changes in the patients’ status. Registered Nurse

Physician

Check the urine ketones if blood glucose is 250 mg/dl and above. Notify the physician for positive ketone bodies. Registered Nurse
Discontinue the infusion as ordered by the treating physician. Registered Nurse

Physician

Check capillary blood glucose 30 minutes after discontinuing the infusion, then repeat every 6 hourly or as may be ordered by the physician, and if any change (deterioration) in the level of consciousness. Registered Nurse

Physician

ATTACHMENTS:

REFERENCE

  • CBAHI 3rd Edition Standards
  • JCIA 5th Edition Standards
Permanent Pacemaker Policy

NURSING MANAGEMENT OF PATIENT WITH PERMANENT PACEMAKER POLICY

 

permanent pacemaker policy

Cardiac Pacemaker – is an electronic device that delivers direct electrical stimulation to stimulate the myocardium to depolarize, initiating a mechanical contraction. Pacing may be accomplished through a permanent implantable system, a temporary system with external pulse generator and percutaneously threaded leads, or a transcutaneous external system with electrode pads placed over the chest.

PERMANENT PACEMAKER POLICY

  1. A credentialed physician will oversee the pacemaker management and manipulation.
  2. Only CCU/ICU Registered Nurses who have demonstrated competency may nurse the patient with pacemaker as per physician order.
  3. All patients with permanent pacemaker will be continuously monitored for heart rate and rhythm after pacemaker insertion.
  4. Adequate cardiac output will be ensured with efficient monitoring of vital signs and urine output.
What do be done…? or what are the steps included in Permanent Pacemaker Policy Who should do it…?
Provide postoperative monitoring, analgesia and care as ordered. CCU/ICU Registered

Nurse

Provide an electronically safe environment for the patient that can interfere with pacemaker function or cause pacemaker failure and permanent pacemaker damage. and to follow the steps in the Permanent Pacemaker Policy CCU/ICU Registered

Nurse

Physician

Avoid use of electric razors, direct placement of defibrillator paddles over pacemaker generator and exposure to MRI. CCU/ICU Registered

Nurse

Physician

Alarm limits will be set 5 beats below rate limit and 5 to 10 beats above upper rate limits. CCU/ICU Registered

Nurse

Physician

Monitor pacemaker function with cardiac monitoring and 12 lead ECG. CCU/ICU Registered

Nurse

Record ECG rhythm strip, inspect for pacemaker spikes and evidence for failure to sense or failure to capture according to the Permanent Pacemaker Policy. CCU/ICU Registered

Nurse

Physician

Assess the patient’s vital signs and hemodynamic status with adequate tissue perfusion and cardiac output as evidenced by optimum level of consciousness, free from dizziness, shortness of breath, chest discomfort or lightheadedness. CCU/ICU Registered

Nurse

Assess/Report for dysrhythmias and treat as indicated. CCU/ICU Registered

Nurse

Physician

Monitor for signs and symptoms of pneumothorax. CCU/ICU Registered

Nurse

Restrict movement of affected extremity and resume range of motion of extremity gradually. CCU/ICU Registered

Nurse

Assess the pacemaker pocket in the acute post implant phase for evidence of hematoma / bleeding. CCU/ICU Registered

Nurse

Monitor for evidence of lead migration and perforation of heart by observing for muscle twitching, cough, chest pain and signs and symptoms of cardiac tamponade. CCU/ICU Registered

Nurse

Assess for signs and symptoms of infection, as redness, edema, drainage, elevated white blood cell count, continued pain and elevated body temperature. CCU/ICU Registered

Nurse

Physician

Effective pain management measures will be instituted as ordered. CCU/ICU Registered

Nurse

Physician

Pain Management

Nurse

Provide appropriate teaching on pacemaker placement, how it works, settings and signs of pacemaker malfunction to report. CCU/ICU Registered

Nurse

Physician

Patient Educator

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