【持续性肾脏替代治疗CRRT英文ppt课件】NursingIssues-in-Pediatric-C

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Nursing Issues in Pediatric CRRT,Helen Currier BSN, RN, CNN,Assistant Director Renal, Pheresis,Scholar Center for Clinical Research,Nursing Issues in Pediatric CR,1,CRRT Treatment Responsibilities:Points to Remember,Nephrology Nurse,Initiate treatment based on individual patient needs as assessed by the nephrologist,Bedside Nurse,Do not infuse other medications or blood products directly into the CRRT system,Cooling effects of CRRT may prevent temperature elevation,Adjust patient fluid removal rate hourly to maintain net UFR,Changes in net URF,CRRT Treatment Responsibilitie,2,Before TreatmentEquipment/Supplies,Nephrology Nurse,Prisma/Prisma tubing,Bedside Nurse,Order dialysis fluid; citrate and any replacement solutions,IV tubing for each infusion pump,3-way stopcocks,Extracorporeal circuit warmer,Extracorporeal circuit prime,Telephone at bedside,Before TreatmentEquipment/Sup,3,Before TreatmentEquipment/Supplies,Nephrology Nurse,Review and note CRRT orders,Verify consent,Notify bedside nurse of treatment orders and initiation time,Set-up and prime CRRT circuit with heparinized normal saline,Prime other lines in CRRT circuit,Verify catheter placement,Bedside Nurse,Review, clarify, and note CRRT,Draw baseline labs per CRRT orders,Explain procedure and answer questions as needed,Check cannulated limb for circulation,Before TreatmentEquipment/Sup,4,Catheter Issues,Design *largest diameter w/shortest length,Diameter,19%, = flow 2x,50% = flow 5x,Increasing from 2.0mm to 2.1 mm increases flow 21%,Length,19%, in diameter will compensate for doubling of length,Placement,Site *RIJ (LIJ, IVC, Subclavian),Tip *well within the atrium,Catheter IssuesDesign *largest,5,Catheter Issues,Catheter flow,Early malposition,Kink,Tip malposition too high/low,Tip malposition arterial against the wall,Tight suture,Tip in wrong vessel,Late thrombosis or fibrin sheath formation,Catheter IssuesCatheter flow,6,Catheter Issues,Catheter related infection,Local,Exit site s/s redness, drainage, crusting, swelling, odor, or pain,Tunnel s/s swelling, pain, redness or ability to express draining down the tunnel track to the exit site,Systemic,Catheter related bacteremia,Catheter IssuesCatheter relate,7,Treatment Initiation,Nephrology Nurse,Assess patients condition *fluid and electrolyte,Prep catheter ports,Aspirate appropriate blood volume from catheter and flush w/saline,Prime CRRT circuit w/priming solution and attach blood lines of equipment to catheter(s),Start citrate drip,After 5 w/stable VS, start replacement fluid and ultrafiltration,Change catheter site dressing if needed,Bedside Nurse,Assess patients condition *fluid and electrolyte,Baseline VS, Wt, PAWP (if applicable), CVP, BP, edema, lung/heart sounds, lab values,VS q 30 x 2 then q 1 h,Monitor and document starting AP, VP, DFR, RFR, BFR, URF and infusion pump rates,Treatment InitiationNephrolog,8,Nephrology Nurse,How CRRT works,Reason for treatment,When and how to terminate treatment,Equipment operation,Most common alarms,When and how to reach the nephrology team,Fluid balance calculations,Assessment of clotting,How to adjust AP/VP limits, BFR, or UFR,How to verify dialysis fluid or replacement fluid and/or rate changes,Nephrology NurseHow CRRT works,9,Bedside Nurse: Competencies,Verbalize,How CRRT works (fluid and solute balance, changes in nutrition and medications),Reason for treatment,When and how to terminate treatment,How to troubleshoot alarms (AP, VP, blood leak, error codes, air detector),When and how to recirculate the system,How to care for catheter and catheter exit site,When and how to contact nephrologist or nephrology nurse,How to operate extracorporeal circuit warmer,Bedside Nurse: CompetenciesVer,10,Bedside Nurse: Competencies,Demonstrate,How to calculate fluid balance,How to assess clotting in the system,How to adjust AP and VP limits, BFR, UFR,How to verify dialysis and replacement fluid solution and rates,Document continuing care in nursing notes and flow sheet,Bedside Nurse: CompetenciesDem,11,CRRT Treatment Responsibilities:q 1 hour,Bedside Nurse,Monitor system for kinks, loose connections, patient bleeding,Evaluate changes in pressure reading VP or AP,Evaluate hemofilter and venous chamber for clotting or fibrin,Evaluate color of ultrafiltrate (no pink-tinged fluid),Document arterial pressure (AP), venous pressure, BFR, and intake/output,CRRT Treatment Responsibilitie,12,CRRT Treatment Responsibilities:q 2 hr into treatment/ q 6 hr thereafter,Bedside Nurse,Check circuit ionized Ca,+,(sample from venous port) and patients ionized Ca,+,(sample from site other than CRRT circuit),Recheck CRRT circuit/patient ionized Ca,+,after any changes in anticoagulation reference optimal ranges specified,Notify nephrology nurse if circuit clots,CRRT Treatment Responsibilitie,13,CRRT Treatment Responsibilities:q 24 hr,Bedside Nurse,Assess patients fluid/electrolyte balance and overall condition, PAWP (if applicable), CVP, edema, lungs, heart,Evaluate serum chemistry for changes,Monitor serum calcium and pH for signs of citrate toxicity,Monitor for s/s of sepsis or local infection,Monitor for s/s of hypothermia,Assess and monitor patients nutritional status daily weight, albumin, bowel patterns, skin turgor, muscle wasting,Monitor the integrity of the access dressing change per protocol,CRRT Treatment Responsibilitie,14,【持续性肾脏替代治疗CRRT英文ppt课件】NursingIssues-in-Pediatric-C,15,Potential Complications with Pediatric Hemofiltration,Circuit Volumes,Hypothermia,Anticoagulation,Fluid Management,Blood Flow Rates,Nutrition,Solutions,Potential Complications with P,16,Circuit Volumes,Significant when dealing with pediatrics,General Guidelines,Circuit volumes should be 10% of the patients blood volume,Hemodynamic instability,Infants,Blood Priming,18,Complications of Blood Priming,Blood Bank pRBC tend to be high in K+,Close K+ monitoring needed at initiation,pRBC HCT are approximately 80%,1:1 dilution with normal saline,Blood prime need to be done at time of initiation.,Citrate binds calcium,hypotension,Complications of Blood Priming,19,Hypothermia,Significant in pediatrics,The smaller the more difficult,Heat loss related to rate of blood flow and volume of blood in circuit,Blood flow rate,Higher blood flow rate decrease heat loss due to less time outside of the body,HypothermiaSignificant in pedi,20,Hypothermia Nursing intervention,External warming devices,Radiant warmers,Baer hugger,Heating mattress,Blood warmers,Solutions heaters,Monitoring,Skin breakdown and patient temperature,Hypothermia Nursing intervent,21,Anticoagulation,Nursing assessment,Monitor ACT q 1-2 hours,via Hemochron,Maintain ACT range 150-200”,Monitor for active bleeding,Monitor circuit for cracks and clotting,AnticoagulationNursing assessm,22,Fluid Management,Ultrafiltration controller necessary,Pumps up to 30% inaccurate,Ultrafiltration rate 0.5-1ml/kg/hr,Difficulty in accurate assessment of measurement of u/f with less room for error in small children,Fluid ManagementUltrafiltratio,23,Fluid ManagementNursing,Accurate Intake and Output assessments,Hourly ultrafiltration calculations,Monitoring vital signs,Heart Rate, CVP, Blood pressures,Patient Weights,q 12 hours or daily,IMPORTANT - Look at your patient,Fluid ManagementNursingAccura,24,Access Difficulties,What is the correct access?,? Best placement,In flow vs out flow difficulties,Access DifficultiesWhat is the,25,In Flow Difficulties,Obstruction or clot “upstream” of inflow,high intrathoracic pressure with HIFI,up against the vessel wall,Clamp on inflow,Access kinked at skin site,Consider reversing or changing access,In Flow DifficultiesObstructio,26,Out Flow Difficulties,Clamp on access/”arterial” line,Inflow port up against vessel wall,Patient “dry” e.g. with femoral site,High of blood flow requirements based upon flow ability of access,Consider,reverse flow, change access, decrease blood flow rates,Out Flow DifficultiesClamp on,27,