Founding RN
Joined: 10 Jan 2003
Posts: 172
PostPosted: Mon Dec 08, 2003 7:47 pm Post subject: Educational Questions, Part 49.
To our Readers and Posters,<
>The best defense in any fight against a disease is education. <
>This column of questions and answers is an attempt in that direction. Anyone is welcome to ask questions. <
><
> What I want to reiterate again is that my answers to your questions DO NOT and SHOULD NEVER take the place of your Dr.'s advice. I am not a Dr. and my answers are based on my many years of experience in the dialysis field. What works for one patient may not work for another. EVERY Patient needs to schedule and attend regular visits with your Dr. in their office.<
><
>This column is for dialysis and dialysis related questions. Please be aware that clinics and companies, machines, policies and procedures vary from place to place. <
><
>I hope that we can help in furthering your dialysis education.
<
>Thank you!<
>Founding RN <
><
>P.S. I work full time so I may not be able to answer your questions right away. But I will get to them ASAP!<
>
************************************************************
BRLA
Joined: 08 Nov 2003
Posts: 22
PostPosted: Tue Dec 09, 2003 1:35 am Post subject: Metabolic Acidosis
What are effects of metabolic acidosis over a 9-month period?
************************************************************
Founding RN
Joined: 10 Jan 2003
Posts: 172
PostPosted: Tue Dec 09, 2003 12:40 pm Post subject: BRLA
Metabolic Acidosis is usually caused by some underlying disease process that must be identified in order to properly treat this.<
><
>In this case I am assuming that you are talking about Renal Failure.<
><
>When the kidneys fail, then waste products are not cleaned from the blood so they build up in the body. For some patients this happens slowly (chronic) and for others it can happen very fast (acute) depending on the underlying cause.<
><
>When metabolic acidosis happens and is not treated the following sypmtoms can show up.<
><
>Cardiovascular: Palpitations, chest pain<
>Neruologic: Headache,vision changes, mental confusion.<
>Gastrointestinal: Nausia & vomiting, abdominal pain,diarrhea, anorexia, weight loss.<
>Musculoskeletal: Generalized muscle weakness & bone pain.<
>Pulmonary: Hyperventilation, intense respiratory effort.<
>Physical: Lethargy, stupor, coma, and death if not treated.<
><
>These are just a few of the symptoms and patients may not have all.
************************************************************
BRLA
Joined: 08 Nov 2003
Posts: 22
PostPosted: Fri Dec 12, 2003 9:55 am Post subject: Creatinine and Tachycardia
Two subjects.<
><
>1. Creatinine - What does increase from 6.0 to 11.0 indicate? What is an acceptable normal level for a diabetic dialysis patient?<
><
>2. Tachycardia - What is tachycardia (I've been told that it is a state when patient's pulse rate is greater than 100. I have also been told that facility does not become concerned about pulse rate unless it reaches 120.)? What happens at dialysis facility if patient, who has history of hospitalization for atrial fi
illation/flutter presents with pulse rate greater than 100, evidences same throughout and/or at some point during dialysis procedure, and/or completes dialysis at pulse rate greater than 100? Facility's treatment flow sheet's pre and post assessment sections (under Cardiac) show an item: Tachycardia > 100. It is observed that this section never indicates a condition of tachycardia, regardless of pulse rates greater than 100. Why not? <
><
>Thanks for your help.
************************************************************
Founding RN
Joined: 10 Jan 2003
Posts: 172
PostPosted: Fri Dec 12, 2003 6:44 pm Post subject: BRLA
1: An increase in the creatinine can indicate a decrease in kidney function. Esp. if the patient had some kidney funtion when dialysis was started. We like to see the creatinine as low as possible, but it will always be elavated above the normal levels in ESRD patients. If you are seeing an increase, then you may need to discuss with your Dr. a larger kidney and / or longer time on dialysis.<
><
>Tachacardia is a rapid heart rate, usually above 100 beats per min. Many patients do have an increase in heart rate while on dialysis.(90-110) But we don't like to see it above 120 unless it has been determined that this is the norm for that patient. The heart rate should come down to a normal range when the treatment is finished. ( 60-90's)<
><
>In dialysis an increase in heart rate can be an indication that fluid is being removed too fast, the patient has too much fluid to be removed in the treatment time, that the patient has reached the their dry weight, or that the blood flow rate ( pump speed) is too fast and the patient's heart is not tolerating it. What should be tried to decrease the heart rate is: Slow pump speed, turn off fluid removal, give the patient some oxygen, and given a bolus of normal saline. It can take up to 10 min. for this to have an effect on the patient's heart rate. <
><
>In a patient with a history of heart problems, a heart monitor should be applied and a strip run off and sent to the Dr. along with a call to the Dr. This is the only way to be sure that the patient is having Atrial Fib, Ventrical Fib, or other cardiac problems. Or if a monitor is not available and after the run the patient is still having problems, then the patient should been seen by their Dr. or go to the ER for further evaluation. At any time if the patient developes chest pain along with tachycardia, the treatment should be discontinued, the Dr. called and the patient should see their Dr or go to the ER right away.<
><
>Please consult with your Dr. if you are having these problems as they can best evaluate the situation. I can only give you general overview and the common solutions I have used. <
><
>
************************************************************
a patient
Joined: 21 Nov 2003
Posts: 6
PostPosted: Fri Dec 12, 2003 7:14 pm Post subject: high pulse
My pulse frequently jumps up high by the end of tx. It is not due to being too dry. It is due to the fact that my machine frequently
eaks down and the replacement machine is cali
ated differently. If the conductivity runs too low on the alternate machine, I am guaranteed a poor tx with raised pulse. My body will not release fluid at the end of tx without difficulty if the conductivity is too low for my body. I am not a number, but am treated like one. My latest standing pulse was 140 and the staff never notices, not even when it is sky high. Units like mine do not pay attention to details like this or have a single clue what is wrong. Their only concern is on getting their work done as quickly as possible.
************************************************************
BRLA
Joined: 08 Nov 2003
Posts: 22
PostPosted: Sat Dec 13, 2003 3:32 am Post subject: Creatinine and Tachycardia
1. Re Creatinine - Can elevations also indicate increase in weight (muscle mass/
eakdown)? EDW has increased from 60, to 61, to 63, and recently to 64 within the past year.<
><
>2. Re Tachycardia - Sharing: The Cardiologist did have a 24-hr monitor placed on patient, according to his notes to "especially during the day on dialysis to get some idea of what rate control is". Dialysis staff had advanced info re Cardiologist's intent.<
><
>On session prior to "monitoring one", patient had ended dialysis at 1.5kg above EDW. On day with monitor, patient presented with Pre B/P 112/57; pulse 111. EDW = 60.0kg; Pre Wgt = 63.8; Gain = 2.3; TW = 5300; Post Wgt = 60.6; Post b/p = 96/50; pulse 83.<
><
>Most interesting observation on tx flow sheet was BFR/DFR which were usually 400/600 (prescription) and occasionally 400/700. On the day with monitor, rates were 300/500 -- the lowest ever at a facility over 4.5 years of tx.<
><
>Pulse rate was lowered during first hr of tx to 89. Two and one-half hrs into tx, b/p was 89/49; pulse 117 -- not 50 fluid given at this time; no indication of UF off. One-half hr thereafter, b/p was 91/34; pulse 87. And, one-half after that, b/p was 93/43; pulse 118.<
><
>When DON/Clinic Manager was asked a month later during records review about reason for change in BFR/DFR, response was "I don't know". Needless to say, I could not help but question whether the Cardiologist had received accurate info based on normal flow rates.<
><
>I agree that staff, too often, treat pts as
if they are inanimate objects/numbers. Such is saddening when staff must know that the greatest reason for death of dialysis patients is cardiac-related.
************************************************************
kelso
Joined: 14 Dec 2003
Posts: 1
PostPosted: Sun Dec 14, 2003 8:57 pm Post subject: a & v pressures
Can a & v pressures run higher when I am run on a different machine? Either that or maybe it's the area of my fistula that I have been stuck lately?
************************************************************
patti
Joined: 20 Mar 2003
Posts: 2
PostPosted: Mon Dec 15, 2003 5:08 am Post subject: Sodium
What is the difference between a straight 148 sodium and a 148 linear sodium modeling program with a 140 base? If the SM has a 140 base does that mean it returns to 140 by the end of the program? Why should it be necessary to return it to 140 30 min earlier? That causes the conductivity to plunge and messes up the electolytes. I know its supposed to help with thirst, but it draws out the sodium and then the electrolytes are badly affected that last half hour resulting in high pulse, weakness etc.
************************************************************
Founding RN
Joined: 10 Jan 2003
Posts: 172
PostPosted: Mon Dec 15, 2003 7:51 pm Post subject: BRLA
Answer to # 1. Yes.<
><
># 2. I agree. The cardiologist did not get accurate information. For accurate information, the dialysis runs should have been consistant with all previous runs which should follow the perscribed treatment orders.
************************************************************
Founding RN
Joined: 10 Jan 2003
Posts: 172
PostPosted: Mon Dec 15, 2003 7:53 pm Post subject: kelso
It might be possible, but most likely due to placement of the needles.
************************************************************
Founding RN
Joined: 10 Jan 2003
Posts: 172
PostPosted: Mon Dec 15, 2003 8:03 pm Post subject: Patti
Straight Sodium: The sodium stays at 148 and does not drop below that until the last 30 min of the run, when it drops down to the base of 140.<
><
>Linear: The Sodium starts at 148 and gradulaly drops down to the base of 140 by the end of the run.<
><
>The reason that we want the Sodium down to the 140 base the last 30 min of the run is that if left higher than that, the majority of patients expereince an increase in thrist and have a very difficult time controling their fluid intake. This results in high fluid intakes, that over time increase the stress on the heart, which in turns leads to Congestive Heart Failure. And a high sodium makes patients retain fluid, which makes it hard for the machine to remove and often results in severe cramps, sudden drops in BP, and miserable runs.<
><
>By having the Sodium return to 140 the last 30 min of the run, it gives the body time to adjust and the electrolytes to stabilize. What you may need to do it have the tech program your machine so that you have removed all but 300-500 cc's of your fluid gainby the last 30 min. That way you can coast those last 30 min and not have much fluid to remove.<
><
>I would reccomend that you use the linear program, that way it comes down gradually over your whole run. This works for the majority of patients.
************************************************************
Founding RN
Joined: 10 Jan 2003
Posts: 172
PostPosted: Mon Dec 15, 2003 8:08 pm Post subject: For the rest of Dec.
My family and the Holidays are my main priority until after the New Year. I will not be checking the computer very often so I appologize if your questions are not answered quickly. I will be back after the New Year in a more timely fashion. <
><
>MERRY CHIRSTMAS AND HAPPY NEW YEAR TO ALL!
************************************************************
patient
Joined: 29 Oct 2002
Posts: 137
PostPosted: Sun Dec 28, 2003 9:29 am Post subject: Sodium Modeling
I recently tried linear 145 and it worked very well for me. Previously, my sodium was run at a 140 straight sodium (no modeling), the conductivity on my machine was 14.2- 14.3 and I did well with this for many months of txs. But when the machine tech took my machine for maintenance, he recali
ated the cond. to 13.8 and I was no longer havinging good txs. Also, anytime I was put on an alternate machine, because my machine
oke down, if the cond was in the 13's, I had a very uncomfortable and/or hurtful tx. If put back on a machine with cond in the 14's, I did fine again. So, since the only thing that changed was the cond. I could see that the solution mix and/or cali
ation of cond was the problem.<
><
>Linear 145 works well for me if the starting cond of my machine is 14.0 or higher. If the starting cond is lower, it will not work as well, and only if I reset the sodium modeling when the cond drops to 14.0. I may have to reset it about twice a tx. <
><
>I have suffered so many uncomfortable or very hurtful txs because my staff and doctor knew nothing about sodium/ conductivity and how it affected my body. And when I told them what I was experiencing, they didn't believe me. <
><
>In a unit with knowledgeable doctor and staff, how is it determined what sodium rate/program the patient should run at? As a patient who has been run on wrong sodium and been affected by low cond, I know it is essential that these settings be correct for each individual patient.
************************************************************
patient
Joined: 29 Oct 2002
Posts: 137
PostPosted: Sun Dec 28, 2003 9:39 am Post subject: SM
Another question I have is, with my linear 145 program, the base sodium is set for 140. My tx time is 4 hrs. If the PGT clock is set for 4 hrs., does that mean the sodium reaches 140 by the very end of the tx or by maybe 30 min from the end of tx?
************************************************************
Max
Joined: 29 Dec 2003
Posts: 1
PostPosted: Mon Dec 29, 2003 2:14 pm Post subject: Changes in conductivity
One tx, the conductivity on my machine will be 14.2 and the next tx the cond will be 13.7. This is the same machine. It has not been taken away and recali
ated. So, what makes the cond change?
************************************************************
Founding RN
Joined: 10 Jan 2003
Posts: 172
PostPosted: Tue Dec 30, 2003 7:05 am Post subject: Patient Reply with quote
It usually is a unit policy as to which Sodium program patients are started on. But most places will allow you to tailor the program to the patient's needs. But not everyone is eduated or takes the time to figure this out.<
><
>If the clock on the sodium program is set for 4 hours and your runis 4 hours, then you will reach the base of 140 right in the last minutes of your run. If the sodium clock is set for 3.5 hours and your run is 4 hours, then you will reach the 140 base 30 min before the end of your run.<
><
>It is usually a unit policy as to how the sodium clock is set. Some units want the sodium to hit the 140 base 15 min before the end of the run, others 30 min before the end of the run. So check with your unit for their policy. <
><
>
************************************************************
Founding RN
Joined: 10 Jan 2003
Posts: 172
PostPosted: Tue Dec 30, 2003 7:10 am Post subject: Max Reply with quote
The most common thing that affects the condo rate is if a sodium modeling program is used or not. If one is not used, then the condo is low. If you are having problems. then I would reccomend that you use a sodium modeling prgram such as a linear program where the sodium starts out high and slowly falls to a base of 140, 15-30 min before the end of your run. This may help you get a more consistant condo and comfortable run.<
><
>The dialysate flow rate and how the bicarb is mixed can affect the condo rate also.
