MEDICINE FOR ALL

Patients who shorten their prescribed dialysis session endanger their health

Try and establish the reason for shortening of session:

• Does the patient have an important commitment elsewhere at that particular time e.g. funeral, job interview or other medical appointment.
• If there are financial, family/carer responsibilities that are regularly causing treatment shortening consider referral to benefits advisor with patient’s permission
• If patient state they are unwell, try to establish if further medical help is required
• If patient is low in mood and finding dialysis difficult consider psychological referral with patient permission

Post dialysis care:

• As dialysis is  approaching completion, prepare equipment ready to terminate dialysis and disconnect the patient from the machine
• Obtain any required post dialysis blood samples
• Disconnect acces per protocols
• Where possible, encourage patients to be involved in these procedures
• For patients with a kidney dialysis  catheter ensure the patients is aware of keeping their exit site dressing dry and procedures to follow should the catheter become dislodged, bleed or they feel unwell
• For patients with arterial venous fistula or arterial venous graft, ensure the patient is aware of procedures to follow if any bleeding between sessions
• Post dialysis observations (blood pressure, pulse, respiration, temperature and blood sugar in diabetic patients) are be recorded before the patients dismounts the chair/bed

Once dialysis has commenced, all patients can expect to have their dialysis monitored and recorded, any issues shared with the staff actioned. Observation should be recorded in electronic patient records and in dialysis care round document. adequate observations will prevent unexpected dialysis emergencies  and clotted circuits.

• Perform observations (blood pressure, pulse, rate and record machine parameters, dialysis progress and medications adminestered etc). The frequency of observations should be risk assessed. In very stable patients who normally have no adverse dialysis events requiring intervention; observation can be taken pre, midway and post dialysis. Patient that are less stable will require as a minimum hourly observations.
• Patients that are diabetic will require additional blood sugar monitoring, as a minimum pre and post dialysis
• Routine drug  rounds should be completed for e.g. iron and erythropoetin
• Prepare and administer any extra prescribed medication as per protocols e.g. antibiotics
• Chase any recent test results  and ensure actioned appropriately
• Ensure the transport for patient’s return journey is arrenged
• Train patient in self care /shared care competencies if interested

Calculate fluid removal and dialysis plan based on observations and patient assessment. Ensure patient understands the need for any re-setting of dry weight or other changes to treatment.

Review and prepare for any pre-dialysis testing (such as blood borne virus, meticillin resistant staphylococcus aureus, monitoring blood etc). Complete any pre-dialysis checks, to ensure the dialysis is delivered in the correct environment (e.g. isolation or no isolation)

TEMPERATURE

Ideally 35.8-37 C and should be comparable with previous pre-dialysis recording

• Outside this range consider sepsis, hypothermia
• Ensure no obvious access infection following central  venous access device protocol
• Question as to whether patient has been systematically unwell at home e.g. fevers, rigours, poor appetite
• Question patients with regards to localising symptoms of infection (e.g. ear, throat, coryzal, cough), diarrhoea, vomiting, urinary and skin breaks. Take skin swabs, urine cultures if indicated
• Follow blood culture procedure
• Discuss with unit consultant if concerns

RESPIRATORY RATE

Ideally 18-24 rpm

Outside this range consider fluid overload or other respiratory condition, sepsis

BLOOD PRESSURE

Ideally <140/80mmHg. Acceptable up to 160 systolic and 90 diastolic. Higher systolic may be acceptable in patients with a wide pulse pressure and where rapid falls occurs with dialysis.

• If blood pressure has been gradually increasing then consider whether dry weight reduction is required
• If blood pressure persistently > 160/90mmHg then obtain some interdialytic recordings for review by consultant. Ensure up to date information on antihypertensive medications and doses
• If blood pressure is markedly lower than previous pre-dyalisis recordings consider whether  patient is unwell; e.g. sepsis, dehydration

PULSE

Ideal pulse rate is 60-100 bpm and should be comparable with previous pre-dialysing recordings

• Feel rhythm manually to check pulse is regular in addition to machine recording
• Outside of this range consider dehydration, sepsis, cardiac arrhytmia

Review baseline information:

1. Weigh gain – ideally <5% of prescribed dry weight

2. If weigh gains are higher than this:

• Educate patients in safe fluid intake, diet and how to reduce high salt intake        foods
• Review whether there has been a reduction in native urine output;                        perform 24 hour collection (collected on days in between dialysis).                        Consider furosemide prescription in those with native urine output
• If diabetic, review blood glucose levels, as if high this may increase thirst            and the need for fluids
• If diabetic, review blood glucose levels, as if high this may increase thirst            and the need for fluids
• If persistently finishing dialysis above dry weight consider if needs                       reassessment
•  Consider use of blood volume monitoring if available, to help assess fluid              status

3. If weigh gains become  less than previously, consider need to reduce dry weight

4. If patient reports shortness of breath in period before dialysis session consider dry weight reduction

5. If patient reports increasing sub cutaneous oedema consider dry weight reduction