FEMALE CATHETERIZATION Objectives ‘+ To relieve retention of urine * To obtain sterile urine specimen for unconscious client. ‘+ Todetermine total amount of residual urine. ‘+ To empty bladder before any procedure / major surgery. ‘© For bladder irrigation ‘+ For strict urine output monitoring, Assessment ‘+ Check doctor's order for indication of catheterization and any specific order ‘* Determine client's condition and ability to follow instructions. ‘+ Assess client's abilty to assume the dorsal recumbent position Equipment Trolley — Top Shelf Trolley - Bottom Shelf Catheterization set consist of: Cleansing lotion ~ normal saline © galipot Sterile lubricant (eg. KY Jelly) © kidney dish (L) Sterile distilled water / water for injection Drainage bag hanger ‘* dressing forceps X 2 Alcohol hand rub © gauze and swab Extra gauze and swabs sterile hand towel Adhesive tape / micropore tape Foleys catheter: Scissors © Child aged 6 and above: 8-12FR © Female adult: 12-14FR Draw sheet20m! syringe Linen protector / incopad Sterile towel /drape with square hole (fenestral) Mask Urine bag / Drainage bag Disposable gloves. Sterile gloves Receiver Receiver for clinical waste Preparation Identity the client. Perform hand hygiene. © Gather equipment. ‘* Prepare the environment. Implementation NO | Procedure Rational 14. | Greet and explain the procedure to client. Establish rapport, gain cooperation and minimizes anxiety. 12. | Provide privacy. Maintain client’s dignity 13, | Perform hand hygiene, Reduce transmission of microorganism. 14, | Puton mask. To maintain asepsis 15. | Open the catheterization set. 16. | Perform hand hygiene / alcohol hand rub. Reduce transmission of microorganism. 17. | Prepare the catheterization set. Ensure smooth performance 7.1 Pour solution and sterile water, 7.2 Squeeze K-Y jelly,7.3. Add additional required items such as sterile gloves, catheter, urine bag, syringe et 18. | Prepare the client, 8.1 Position the client in dorsal Provide better visualization during recumbent position, procedure, 8.2 Coverclient’s lower abdomen until | Avoid unnecessary exposure to knee with draw sheet. maintain client's privacy 8.3 Place incopad under client's buttock. | Prevent soiling of bedding, 8.4 Remove client's pants or sarong. 19. | Perform surgical asepsis hand wash and | Reduce transmission of dry with sterile hand towel microorganism, 20. | Puton sterile gloves, Maintain sterility and asepsis, 21. | Prepare the sterile equipment. 11.1 Check catheter balloon. Ensure there is no leakage. 14.2. Apply lubricant to the tip of the Prevent traumatizing urethra and catheter and place itin the sterile | maintain sterility. kidney dish. 11.3 Squeeze swabs (minimum 5), loosen one by one and arrange in the kidney dish J galipot. 11.4 Fill syringe with distilled water. 22. | Liftup the draw sheet using the elbow to. | Maintain sterility and asepsis of expose client's perineum. sterile gloved hands, 23. | Drape around client's abdomen and thighs _| Create sterile field and prevent using fenestral towel. catheter from touching the skin. 24. | Clean the vuiva with sterile gloved hand | To reduce the number of (maintain non-touch aseptic technique) or by using a dissecting forceps as per hospital policy (pick up one swab at a time and discard each used swab after one downward stroke) microorganisms, 14.1. Swab the further labia majora 2s14.2 Swab the nearer labia majora 14.3 Discard the dissecting forceps ifitis_ | Forceps is considered used. contaminated 14.4 Separate labia majora with non- dominant hand (leave this hand in place, holding the labia open until the catheter is inserted) 14.5 Swab the further labia minora. 14.6 Swab the nearer labia minora. 14.7 Swab vestibule over the meatus. gently with a downward stroke. 15. | Identity the urethral opening To verity the orifice, 16. | Place sterile kidney dish containing catheter | Maintain sterile field within which and dissecting forceps on the sterile towel _| to work and prevent catheter from in between the client's thigh. touching the skin of client's thigh 17. | Instruct the client to take a deep breath, Helps client to relax. 18, | Hold catheter 2-3 cm from its tip by using | Avoid touching the catheter with dissecting forceps and insert catheter gently | fingers to reduce infection risk. about 4 om or until urine drains out from the catheter. 19. | Continue inserting the catheter slowly just | Ensures the catheter is beyond the beyond the point at which urine begins to | neck of the bladder. flow. 20. | Hold the catheter in place with the dominant | To hold the catheter in place. hand while instiling sterile water into the side arm of the catheter to inflate the balloon with the non-dominant hand. 21, | Retract the catheter gently until you feel This indicates the correct position. resistance. 22. | Attach the end of catheter to the drainage | Allow free flow of urine. bag. 23, | Clean the client's perineum, remove drapes | Ensure client's comfort and dry the genital area. 2624, | Remove sterile gloves and don disposable gloves. 25. | Anchor the catheter to client's inner thigh. | To stabilize catheter, prevent urethral trauma and tension on bladder neck 26. | Reposition client for comfort 27. | Attach the drainage bag to its hanger and | Prevent back flow of urine which hang to the side of the bed frame keeping it | causes ascending UTI and keeps lower than the client's bladder. bag from touching the floor. 28. | Dispose used supplies. 29. | Remove gloves, mask and perform hand hygiene. 30, | Document the following For documentation and further management. 28.1 Date and time of insertion. 28.2. Size and type of catheter. 28.3 Amount, color and characteristic of the urine. Evaluation ‘Surgical asepsis is maintained throughout procedure Assess client's comfort level and any pain associated with the procedure Check catheter and drainage tube: ~ catheter secured over client's thigh, urine bag is hung at a position lower than bladder, drainage tube is patent and free from external pressure or kink Check urine output: draining well, no blockage; characteristics and amount of the urine. Follow up the client periodically to detect any complications early. Report any abnormalities to staff in charge / doctor. 27INTERMITTENT CATHETERIZATION Objectives ‘© Torelieve acute retention of urine. ‘+ To obtain sterile urine specimen for unconscious client. ‘+ To determine total amount of residual urine. Assessment ‘* Check doctor's order for indication of intermittent catheterization and any specific order. ‘+ Determine client's condition and ability to follow instructions. + Assess client's ability to assume the dorsal recumbent position Equipment Trolley — Top Shelf Trolley — Bottom Shelf Catheterization set consist of: Cleansing lotion ~ normal saline © galipot Sterile lubricant (eg. KY Jelly) © kidney dish (L) ‘Alcohol hand rub © dissecting forceps Extra gauze and swabs * dressing forceps X 2 Draw sheet * gauze and swab Linen protector / incopad © sterile hand towel Mask Straight catheter size 12FR (follow hospital practice) Disposable gloves Sterile towel /drape with square hole (fenestral) Receiver Sterile gloves Receiver for clinical waste Urine measuring jugSpecimen botties, compieted laboratory requisition form and Biohazard bag for delivery of specimen to laboratory (or Container specified by an agency) as order Preparation Identify the client, Perform hand hygiene. Gather equipment. Prepare the environment. Implementation NO | Procedure Rational 1, | Greet and explain the procedure to client. | Establish rapport, gain cooperation and minimizes anxiety. 2. | Provide privacy. Maintain client's dignity 3. | Perform hand hygiene. Reduce transmission of microorganism. 4. | Puton mask. To maintain asepsis. 5. | Open the catheterization set 6. | Perform hand hygiene / alcohol hand rub, | Reduce transmission of microorganism. 7. | Prepare the catheterization set: Ensure smooth performance of procedure. 7.1 Pour solution and sterile water. 7.2 Squeeze KY Jelly. 7.3. Add additional required items such as sterile gloves, catheter, syringe etc. 8. | Prepare the client 8.1 Position the client in dorsal recumbent position. Provide better visualization during procedure, 8.2 Cover client’s lower abdomen until knee with draw sheet. Avoid unnecessary exposure to maintain client's privacy. 298.3 Place incopad under client's buttock. Prevent soiling of bedding, 8.4 Remove client's pants or sarong. 9. | Perform surgical asepsis hand wash and —_| Reduce transmission of dry with sterile hand towel microorganism. 10. | Puton sterile gloves: Maintain sterility and asepsis. 11, | Prepare the sterile equipment. 14.1. Lubricate the insertion tip of the Prevent traumatizing urethra and catheter and place it in the sterile | maintain sterility, kidney dish 14.2 Squeeze swabs (minimum 5), loosen one by one and arrange in the kidney dish / galipot. 12. | Lift up the draw sheet using elbow to Maintain sterility and asepsis. expose client's perineum. 13. | Drape around client's abdomen and thighs | Create sterile field and prevent using fenestral towel catheter from touching the skin, 14, | Clean the vulva with sterile gloved hand | To reduce the number of (maintain non-touch aseptic technique) or by using a dissecting forceps as per hospital policy (pick up one swab at a time and discard each used swab after one downward stroke). microorganisms. 14.1. Swab the further labia majora. 14.2. Swab the nearer labia majora 14.3. Discard the dissecting forceps if itis | Forceps is considered used. contaminated. 14.4 Separate labia majora with non- dominant hand (leave this hand in place, holding the labia open until the catheter is inserted). 14.5 Swab the further labia minora. 14.6 Swab the nearer labia minora. 14.7 Swab vestibule over the meatus gently with a downward stroke 3015. | Identity the urethral opening To verity the orifice. 16. | Place sterile kidney dish containing catheter | Maintain sterile field within which and dissecting forceps on the sterile towel | to work and prevent catheter from in between the client's thigh. touching the skin of client's thigh. 17. | Instruct the client to take a deep breath. Helps client to relax. 18, | Hold catheter 2-3 om from its tip by using | Avoid touching the catheter with dissecting forceps and insert catheter gently | fingers to reduce infection risk. about 4 om or until urine drains out from the catheter. 19. | Continue inserting the catheter siowiy just | Ensures the catheter is beyond the beyond the point at which urine begins to. | neck of the bladder. flow. 20. | Hold the catheter in place while urine is flowing, 21. | Inspect the urine for color, clarity, odor and | To detect any abnormalities the presence of any abnormal constituents such as blood. 22. | Using elbow press on the supra-pubic area, | Ensure residual urine is emptied 23. | Remove catheter when urine stop flowing. 24. | Ciean the client's perineum, remove drapes | Ensure client's comfort and dry the genital area 25. | Remove gloves and don disposable gloves. 26. | Reposition client for comfort 27. | Dispose used supplies. 28. | Remove gloves, mask and perform hand hygiene. 29. | Document the following For documentation and further 29.1 Date and time of insertion. 29.2 Size and type of catheter. 29.3 Amount, color and characteristic of the urine. management. 31Evaluation + Surgical asepsis is maintained throughout procedure. + Assess client's comfort level and any pain associated with the procedure, © Check urine output: = amount of urine drained, characteristics and amount of the urine. ‘+ Follow up the client periodically to detect any complications early. © Report any abnormaities to staff in charge / doctor. 32CARE OF CONTINUOUS BLADDER IRRIGATION Objectives + Tofflush clots and debris from bladder following bladder or prostatic surgery (TURP). + Torelieve bladder inflammation. ‘+ To prevent and treat bladder infection. ‘+ To prevent catheter obstruction and promote patency. + To stop bleeding, Assessment ‘+ Check doctor's order for indication of continuous bladder irrigation and any specific order. ‘Determine client's condition and ability to follow instructions. + Note if client has triple lumen indwelling catheter and continuous drainage bag. Equipment Trolley Sterile gloves Irrigation solution (2L — 31 sterile normal _| Disposable gloves, saline) as ordered IV giving set Urine measuring jug Tray consist of: Receiver for clinical waste ‘© alcohol swabs / wipes Receiver for domestic waste sterile gauze Additional: drip stand Preparation Identify client «Perform hand hygiene, + Gather equipment. 33Implementation No | Procedure Rational 1. _ | Greet and explain the procedure to client. | Establish rapport, gain cooperation and minimizes anxiety. 2. _ | Provide privacy. Maintain client's dignity 3, | Perform hand hygiene and don disposable | Reduce transmission of gloves. microorganisms, 4, | Remove protective covering from spike on | Maintain sterility of solution and IV tubing and insert spike into insertion port | prevent contamination. of solution bag / container using aseptic, technique, 5. _ | Hang irrigation solution bag /container on | Prevent air from entering bladder drip stand and prime tubing until air is and causing discomfort. expelled. 6. | Close roller clamp and place linen protector | Prevent soiling of bedding underneath the connection of urinary catheter and tubing. 7. _ | Empty client's urinary drainage bag and Ensure accurate intake and output record amount. recording 8. _| Perform continuous bladder irrigation 8.1 Remove gloves and perform hand —_| Prevent transmission of hygiene. microorganisms. 8.2 Don sterile gloves. Maintain sterility 8.3 Hold the end of catheter with sterile gauze. 8.4 Clean the catheter with spirit swab from the tip to the distal end. 8.5 Connect drip set to 3-way catheter. 8.6 Open clamp on drip set and allow irrigation solution to flow into the bladder. 8.7 Regulate the flow rate as ordered (30-60 drops per minute). 9, | Remove gloves and perform hang hygiene. | Prevent transmission of microorganisms. 3410. | Make the client comfortable. 11, | Infuse continuously to keep urine drainage | Prevent clots forming in the pink to clear as ordered. bladder. 42. | Observe the output of irrigation. Detect complication early 13, | Dispose used supplies and tidy up unit. 14. | Perform hand hygiene. Reduce transmission of microorganisms, 15. | Document in intake and output chart as per | For documentation and further hospital protocol. management, 15.1. Date and time starting irrigation 15.2 Date and time completion. 15.3. Amount infuse and output. 15.4 Color and characteristic of urine 18.5 Any abnormalities or client's complaint Evaluation Surgical asepsis is maintained throughout the procedure. ‘Assess client's comfort level and response to treatment. Check for bladder distention or abdominal pain. Monitor urine output every hourly to observe patency of system. Note characteristic of urine: = color = amount — presence of clots or debris Empty drainage bag as needed. Subtract amount of irigating solution infused from total ‘output to obtain urine output Record intake and output chart accurately. Change irrigation solution bottle / bag using aseptic technique Report any abnormalities such as retention, distention, presence of blood clots or ete. to staff in charge / doctor. 35BLADDER WASHOUT Objectives ‘* Toprevent blockage of the draining system. © Torelieve bladder inflammation. Assessment ‘+ Check doctor's order for indication of bladder washout and any specific order. ‘+ Determine client's condition and abilty to follow instructions, ‘+ Note if client has indwelling catheter and continuous drainage bag Equipment Trolley ~ Top Shelf Cleaning solution ~ surgical spirit 70% Sterile irigation set / dressing set Sterile normal saline for irrigation Catheter tip syringe (50 ml) Tubing clamp (if needed) Sterile bow! / basin /jug Incopad / Linen protector / Mackintosh Sterile spigot ‘Adhesive tape / micropore tape Sterile gloves Urine measuring jug Trolley ~ Bottom Shelf ‘Scissors Disposable gloves. Receiver for clinical waste Alcohol hand rub Receiver for domestic waste Preparation ‘+ Identify client ‘+ Perform hand hygiene. ‘© Gather equipment 36Implementation No | Procedure Rational 4, | Greet and explain the procedure to client. | Establish rappor, gain cooperation and minimizes anxiety. 2. | Perform hand hygiene. Reduce transmission of microorganisms. 3. _ | Provide privacy and place client in a Maintain client's dignity comfortable position. 4. | Place a linen protector / mackintosh under _| This will form a working field for connection of tubing and catheter. irrigating catheter and prevent soiling of bed. 5. _ | Expose the catheter but cover the body of _ | Expose work area and protects the client. client's right to privacy. 6. | Palpate client's bladder for bladder Ensure fluid will not over distend distention the bladder. 7. | Perform alcohol hand rub then open the | To maintain sterility, sterile irrigation set / dressing set. 8. _ | Pour solutions into sterile container / bow / jug. 9. | Open irrigation syringe and place into ‘Avoid contamination of the syringe sterile container / kidney dish tip. 10. | Don disposable gloves Reduce transmission of microorganisms. 11. | Measure the amount of urine in the Ensure all the irrigation solution is drainage bag before beginning the returned irrigation. 12. | Perform surgical hand wash, dry hands Reduce number of microorganisms with sterile hand towel and don sterile and maintain sterility gloves. 13. | Prepare the sterile equipment. 14, | Drape sterile towel near the junction of the | To create a sterile field, catheter and drainage tubing 15. | Hold the distal end of the catheter with Reduce chance of contamination of sterile gauze and disinfect the junction of the catheter and drainage tubing with a surgical spirit swab, the lumen of the catheter or drainage tubing, 3716. | Place your fingers at least 1 inch from the | Prevent contaminating tip of tubing junction, disconnect catheter from drainage | and to keep the drainage tubing tube. Cover the end of the drainage tube | sterile. with sterile gauze. 17. | Place the disconnected tubing at the distal | Prevent contamination of tubing, end of the sterile field. 18. | Place catheter end into irrigation set / sterile | Prevent contamination kidney dish. 19. | Expel air from syringe then inser irrigating | Debris can be forced into bladder syringe into catheter and attempt to aspirate | and result in infection, any obstructing debris. 20. | Withdraw irrigation solution into syringe and | Air may cause discomfort of expel air in the syringe. bladder. 21. | Fitthe irrigation tip into the end of catheter carefully. 22. | instill 30-50 ml of solution into catheter with | Too much force may damage the a gente pressure, bladder lining or cause bladder spasms. 23. | Remove the syringe and allow fluid to drain from the catheter into receiver. 24. | Repeat steps 19 - 22 and continue to irrigate client's bladder with 30-50 ml of solution until fluid running freely and the retums are clear or catheter unclogged. 25. | Remove the gauze from drainage tube. 26, | Clean end of catheter with surgical spirt | Restores the closed drainage swab, and reconnect the catheter to the system without contaminating drainage tube, keeping both ends sterile. _| either the catheter or the tubing. 27. | Perform catheter care. Removes any leakage of urine. 28. | Remove gloves, perform hand hygiene and don disposable gloves. 29. | Secure catheter to client's inner thigh and _| To stabilize catheter and prevent attach the drainage bag to its hanger and | back flow of urine. hang to the side of the bed frame keeping it lower than the client's bladder. 30. | Make the client comfortable and tidy up unit 3831, | Measure amount of fluids return. Subtract amount of irrigating solution used to irrigate. 32, | Remove gloves and perform hand hygiene. | Reduce transmission of microorganisms. 33, | Record net amount on client's intake and —_| For documentation and further output chart, management. Evaluation ‘+ Surgical asepsis is maintained throughout the procedure. ‘+ Assess client's comfort level and response to treatment, «Assess if the catheter is draining properly without blockage. ‘+ Assess the characteristic of urine output, clarity and without clots, sediments or debris. ‘+ Assess the effectiveness of procedure. ‘+ Conduct appropriate follow-up based on findings that deviate from expected or normal for the patientictient. Relate findings to previous assessment data if available. ‘+ Advise client to report any discomfort or pain. ‘+ Report any abnormalities to staff in charge / doctor. 39ASSIST IN PERITONEAL DIALYSIS AND CARE OF CLIENT UNDERGOING PERITONEAL DIALYSIS Objectives To remove excess electrolytes, waste products and excess water from the client's body, ‘To manage end-stage renal failure and prevent uremia. To ensure the procedure is done safely and effectively. Assessment Identify client Check doctor’s order for indication of peritoneal dialysis and any specific orders Determine client's general condition and effort tolerance. Assess baseline vital signs to help evaluate the effects of peritoneal dialysis: temperature pulse rate respiration rate ~ blood pressure = pain score Measure and record client's weight and abdominal girth. Note laboratory investigation result such as BUN, serum electrolyte, creatinine and hematocrit level. Equipment Trolley — Top Shelf Trolley — Bottom Shelf Peritoneal dialysis set consist of: ‘Tray consist of: © 3 galipot © LA= lidocaine 1% or 2%, syringe 10 ml and needles - 21 & 25 G) © 2kidney dish (L & M) ‘© gauze and swabs '* sponge holding forceps © extra suture & scalpel blade * toothed & non-toothed dissecting ‘+ elastoplast/ plaster! micropore forceps ‘* artery forceps * scissors, © scalpel holder Povidone 40© needle holder ‘Surgical spirit 70% scissors Sterile gloves © gauze Disposable gloves * sterile hand towel Mask ‘sterile towel /drape with square hole (fenestral) Peritoneal dialysate (1.5%, 4.5%) as order Suture 2/0 mersilk Peritoneal dialysis transfusion set, Scalpel biade size 14 Drawsheet / Linen protector Sterile gloves Urine measurement jug Sterile urine bag Receiver Peritocat set Receiver for clinical waste Receiver for domestic waste Biohazard sharp bin ‘Additional: drip stand Trolley - for continuous care Tray consist of: Peritoneal dialysate (1.5%, 4.5%) © spirit swab / wipe Basin for warm water * heparin Receiver for domestic waste syringe and needle Biohazard sharp bin Urine measurement jug Peritoneal dialysis chart 41Preparation © Verify client and confirm client's schedule for peritoneal dialysis. ‘+ Ensure consent has been obtained by doctor. + Ensure baseline vital signs have been taken for comparison. ‘+ Perform hand hygiene. ‘+ Warm the dialysate to body temperature to reduce discomfort and prevent hypothermia. «Get ready drip stand and prime the giving set with warmed dialysate. ‘+ Gather other needed equipment, drugs and disposable items as required. ‘© Prepare the environment. Implementation NO | Procedure Assists in peritoneal dialysi 1. | Greet client. Establish rapport. 2. | Explain the procedure to client. Gain cooperation and ensure lent is well prepared emotionally 2.1 Procedure is done under LA. and physically and to minimizes anxiety. 2.2 The common sensation associated with peritoneal dialysis, such as pressure during catheter insertion and fluid retention. 2.3 Minimize movement during procedure. 3. _ | Instruct client to empty bladder or Reduce risk of puncturing internal catheterization will be done for unconscious | organs. client. 4, _ | Provide privacy and position client in Maintain clients dignity recumbent, 5. _ | Shave the incision area (abdomen, below umbilicus to symphisis pubis). 6. _ | Provide continuous emotional support and | Allay anxiety, gain cooperation observe client's condition throughout the —_| and detect any abnormalities procedure. early. 7. _ | Assist doctor in insertion of peritoneal catheter. 7.1 Abdomen is surgically prepared with | Eliminate bacteria and decrease local antiseptic. wound contamination. 7.2 Drape with sterile towe!. 427.3 Local anesthesia will be given To anesthetizes the site, 7.4 Assmall incision is made below the | This area relatively ree from large umbilicus by the doctor. vessels. 7.5 Trocar'is inserted through the Anchor the catheter to prevent incision with a stylet in place. dislodgement. 7.6 Ifclient is conscious, advice him / her | Permits trocar insertion without to raise his / her head to tighten damaging intra abdominal organ. abdominal muscles. 7.7 After trocar is removed, a purse string suture is done by doctor. 7.8 Perform sterile key hole dressing. 8. | Connect administration giving set to Reduce risk of infection. peritoneal catheter under aseptic technique. 9. | Add heparin to the dialysate as ordered. _| Prevent fibrin clots in catheter. 10. | Ensure dialysate flow steadily without Ensure patency. kinking, 11. | Observe vital signs as scheduled or more | Detect any complications and frequent if necessary: abnormaities © % hourly for 1 hour = hourly for 2 hours ‘© Hourly til end of procedure Continuous care during peritoneal dialysis 12, | Monitor client’s condition and flow of Detect any complications and dialysate abnormalities ‘+ General condition of client © Characteristic of flow * Patency ‘* Inflow and outflow amount 13. | Ensure restrict fluid intake as ordered by doctor. 14. | The procedure is repeated until the blood chemistry levels improve or as ordered by doctor. (Add heparin into dialysate as ordered.) 15. | Record inflow and outflow amount For documentation and further accurately. management. 4B16. Made the client comfortable, Evaluation ‘Assess client's response to treatment and comfort level by comparing pre and post dialysis assessment, including subjective and objective data, Surgical asepsis is maintained during the dialysis procedure and when caring for the peritoneal catheter. Assess status of catheter site for bleeding, ‘Assess for any complications or adverse responses to dialysis, ‘Advise client to report any discomfort of bleeding from wound. Inform any abnormalities to staff in charge / doctor. ‘Assess the blood chemistry level Assess the effectiveness of procedure Weigh the client daily Encourage deep breathing and coughing exercise 44ASSIST IN HAEMODIALYSIS AND CARE OF THE CLIENT UNDERGOING HAEMODIALYSIS IN HAEMODIALYSIS CENTER Objectives ‘+ To remove excess electrolytes, waste products and excess water from the client's body, + To manage end-stage renal failure and prevent uremia, = To ensure the procedure is done safely and effectively. Assessment * Check doctor's order for indication of haemodialysis and any specific orders «Identify client and determine client's general condition and effort tolerance, ‘+ Assess baseline vital signs to help evaluate the effects of haemodialysis: = temperature — pulse rate — respiration rate = blood pressure ~ pain score + Weigh the client. + Assess vascular access site (fistula) for — palpable pulsation or vibration = thrill — inflammation = haematoma Equipment Trolley — Top Shelf Trolley — Bottom Shelf Dressing set Tray consist of: Drape / sterile towel © heparin vial 5,000 units/ml! & Erythropoietin Stimulating Agents (ESA) AV needles: © micropore IV drip set © scissors Machine bloodlines ‘Surgical spirit 70% New or reuse dialyser (hollow fiber or Concentrate “A” and “B* cellulose acetate) 48Normal Saline 0.9% IV solution Disposable gloves Sterile gloves Plastic gown Sterile gauze, alcohol swabs, povidone- iodine swabs Protective goggles and face mask or visor shield as needed 10 mi syringe x 2, 20 mi syringe x 2 Receiver for clinical waste Receiver for domestic waste Biohazard sharp bin Preparati Register client and confirm client's schedule / appointment for haemodialysis. Perform hand hygiene. Gather equipment, drugs and disposable items as required. Prepare and test haemodialysis machine as per operator manual and unit policy and standard of practice (SOP) Prepare anticoagulant and disposable consumables: = Withdraw 2 mis (5000 units/ml) of heparin Dilute with 8 mis of normal saline (Heparin 10,000 units in 10 mis) ~ Prepare heparinised saline by injecting 1 mi of heparin (1000 units/m! bottle of 500 mis of normal saline and label. ‘Complete priming procedure for dialyser (either new or reuse dialyser) and bloodlines with heparinised saline accordingly (refer as in operator manual and unit policy) Set haemodialysis parameter as prescribed by doctor, which includes duration of treatment, ultrafitration and heparinisation. Hang additional IV solution of normal saline (saline solution must be available immediately for rapid reversal of hypotension or discontinuation of dialysis). Implementation NO | Procedure Rational Assist in Initiating Haemodialysis for Client with AV Fistula 1. | Greet and explain the procedure to client. | Establish rapport, gain cooperation and minimizes anxiety. 2. | Made client comfortable in dialysis chair. 463. | Perform hand hygiene. Reduce transmission of microorganisms, 4. | Don mask and gown. Put on goggles if ‘Adherence to the practice of needed. standard precaution, 5. _ | Prepare dressing set and items needed for_ | Ensure smooth performance of cannulation. procedure. 6. _ | Don disposable gloves, and remove dressing if used 7, _ | Remove and discard gloves. Gloves are contaminated 8. _ | Perform surgical asepsis hand wash. Reduce transmission of microorganisms. 9. | Don sterile gloves. To maintain asepsis. 10. | Assist staff nurse in cleaning vascular Reduce the number of access site (AV fistula) using surgical spirit | microorganisms of the site ‘swab, then povidone-iodine swab using circular motion. Allow to dry. 11, | Assist staff nurse in performing cannulation using surgical asepsis and secure with micropore to extremity, ‘+ arterial fistula cannulation ‘+ venous needle cannulation 12. | Assist staff nurse in obtaining blood for pre- dialysis blood samples as ordered by doctor (e.g. electrolytes, hematocrit, clotting time) Observe and assist where applicable of the following steps 13 - 24 13. | Start blood pump (100 ml/min) Flush out the heparinised saline from the bloodline and dialyser 14. | Inject bolus 3000 unit heparin or as prescribed by doctor into the extracorporeal circuit when blood reaches the arterial chamber and mount the syringe to the heparin pump. 15. | Off blood pump and clamp the venous bloodline when venous chamber is filled with blood. 16. | Swab the needle end of venous bloodiine | Maintain sterility and prevent with antiseptic and connect to the venous AVF needle. contamination. 4717, | Unciamp the venous bloodline and expel air | Prevent air embolism bubbles if any. 18. | Unciamp venous AVF needle and activate | Detect presence of air to prevent air bubble detector. embolism. 19. | Connect the venous and arterial pressure monitoring line to the respective monitor port and unclamp. 20. | Tum the dialyser with arterial end up. 21, | Tum on biood pump to a speed of 100 — 150 misimin and activate UF controller. 22, | Note time of dialysis initiation Ensure accuracy of procedure. 23. | Check that all connections and blood tubing | Prevent dislodgement of cannula are tape securely to client's extremity and complication 24, | Gradually increases the biood pump speed | Prevent complications. to the prescribed blood flow rate (usually 300 - 450 ml/min) 25. | Made the client comfortable and tidy up unit 26. | Remove gloves, mask and perform hand | Reduce transmission of hygiene. microorganisms. 27. | Documentation (refer as in the For continuity of care plan haemodialysis treatment record) ‘Ongoing Care of Intradialytic Client 1. _ | Observe neurological status. Detect fluid and electrolyte imbalance. 2. _ | Monitor vital signs 2 hourly or more frequent | Hypertension may indicate excess as necessarily. fluid volume; hypotensive client ‘+ Blood pressure may not tolerate rapid fluid volume ‘© Respiration rate changes during dialysis. = Pulse rate ‘+ Body temperature Pain score 3. _ | Auscultate for any abnormal heart and lung | Indicative fluid overload or sounds, electrolyte imbalance. 4, | Limit fuid intake to prescribed amount (e.g. | Prevent fluid overload, 1500 mi/ day), 485, _ | Advice individualized diet as prescribed high quality protein 1.1 g/kg ideal body weight / day; sodium 70 megiday, potassium average 70 mEqiday. 6. _ | Ensure access connections are visible and _ | Prevent possible infection, provide care of access site 7. | Encourage regular rest periods. Promote comfort. 8. _ | Provide continuous emotional support. ‘Alay anxiety, 9, _ | Assist client during meal time. 10. | Assist clientf any problem arises, 11. | Inform staff nurse / doctor if any medical | For early intervention and further problems arise. management. 12, | Ensure documentation up to date For continuity of care. ‘Assist in Terminating Hemodialysis and Providing Post 1. ] Note time upon termination of treatment. | Ensure accuracy of procedure 2, | Don disposable gloves, plastic gown and | Adherence to the practice of protective mask (if needed). standard precaution. ‘Observe and assist where applicable the following steps 3 - 14: 3. | Disconnect IV set from the infusion line, fix a connector and withdraw 10 mis normal saline. 4. | Off bicod pump. 5, | Clamp and disconnect the arterial needle and arterial bloodline. 6. _ | Flush arterial needle tubing and recap. 7. _ | Setdialysate to by-pass 8. | Connect the arterial bloodline to the IV set 9. | Unciamp the IV set and the arterial bloodline, 4910. ] Turn on blood pump. 11, | Stop blood pump when the venous needle is cleared of blood, and clamp the venous needle and the venous bloodline. 12. | Disconnect the venous needle from the venous bloodline. 13. | Remove AVF needles and apply continuous | To stop bleeding, moderate pressure with a piece of sterile gauze. 14, | Apply sterile swab over the cannulation site and secure with plaster. 15. | Discard all used disposable items into the | Adherence to unit protocol and clinical waste bin practice of standard precaution. 16. | Remove gloves and plastic apron, and perform hand hygiene. 17. | Measure and record post-dialysis vital Evaluate effectiveness of signs, weight and vascular access site haemodialysis treatment. condition. 18. | Administer Erythropoietin Stimulating Improve hemoglobin level Agents (ESA) as ordered by doctor, for example, SIC Eprex or Recomon. 19. | Make the client comfortable. 20. | Complete all necessary documentation. Evaluation ‘Surgical asepsis is maintained throughout the procedure. Client is comfortable throughout the procedure. Assess client's response to treatment and comfort level by comparing pre and post dialysis assessment, including subjective and objective data Assess status of vascular access site (AV fistula) for bleeding and distal circulation, Assess for any complications or adverse responses to dialysis, such as: nausea and vomiting = dehydration — hypotension ~ headache = muscle cramps — seizure activity Inform any abnormalities to staff in charge / doctor. Allow client to go home if there is no complications. Remind client of next dialysis schedule. 50