If a dialysis center carries out dialyzer reprocessing and uses peracetic acid as the germicide, the contact time needed is 11 hours. Only one germicide may be used, but there are four main types: peracetic acid (most commonly used), glutaraldehyde (10 hours contact time), formaldehyde (24 hours contact time), and heat disinfection (with citric acid) (20 hours contact time). Peracetic acid is more expensive than most other germicides, but it poses less of a risk to those using the germicide than do formaldehyde or glutaraldehyde.
Patients receiving hemodialysis are at risk for amyloidosis, which is characterized by joint pain. With amyloidosis, a waxy amyloid protein builds up in bones, joints, and other soft tissues. Proteins are normally soluble in water, but amyloid proteins are not, so they deposit in tissues. Dialysis-associated amyloidosis usually occurs after five years of hemodialysis, and the risk increases with years of hemodialysis. Common complications include carpal tunnel syndrome, pain in the shoulders, and joint damage. Amyloidosis may cause skeletal deformities and fractures.
If a patient complains of persistent itching, taking oatmeal baths may help to soothe the skin and relieve itching. Keeping the skin well moisturized may also help. Itching is a problem for most kidney dialysis patients. The nurse should always evaluate patients with itching. Itching may result from hyperparathyroidism, so treating that may help alleviate symptoms. If the patient's phosphorus levels are too high, phosphate binders may help.
The aluminum level in dialysis water should be less than or equal to 0.1 mg/L. Aluminum is often present in municipal water supplies, but people on dialysis are not able to remove aluminum from the body, so the aluminum can build up in the body and result in anemia and encephalopathy (damage to the brain), leading to dialysis dementia. If the exposure occurs over a long period, aluminum may also cause aluminum-related bone disease.
As part of anemia management for patients receiving hemodialysis, the technician should rinse back as much blood as possible. Longer treatments pose less risk of anemia than shorter treatments. High-calorie snacks are usually high in carbohydrates or fats rather than protein. Whether or not a patient is to receive oral protein supplements during hemodialysis depends on the nephrologist's assessment and orders. Severe anemia may be treated with an erythropoiesis-stimulating agent to increase the production of red blood cells.
The duties that the technician is allowed to carry out depend primarily on the state regulations and standards of practice. Although certified technicians should receive similar training, some states allow technicians to cannulate accesses and to administer intravenous heparin, whereas others do not. The technician should always know what is allowed in the state in which the person is working. Even if a state allows a technician to carry out certain duties (such as administering heparin), a dialysis center may further restrict the technician's role.
One of the functions of the End-Stage Renal Disease (ESRD) Networks is to help centers resolve patient-staff conflict. ESRD Networks are located in various areas of the country (18 total) and were set up by Congress to ensure quality dialysis care. The ESRD Networks have contracts with Medicare to collect data, create reports, promote rehabilitation, carry out improvement projects, and provide resources for patients and healthcare providers. All dialysis centers are required to work with ESRD Networks.
To reinforce teaching, the technician should remind patients with kidney failure that they should avoid smoking. Smoking is a risk factor for atherosclerosis. Additionally, smoking results in constriction (narrowing) of the vessels, which can further decrease the glomerular filtration rate and impair general circulation to the kidneys. Although X-rays pose no particular risk, contrast dye should be avoided. Acetaminophen can be used, but nonsteroidal anti-inflammatory drugs should be avoided. Patients should be encouraged to exercise tolerance.
Although the medical director of a dialysis center must lead the quality assessment and performance improvement (QAPI) program, it is the responsibility of all staff members to carry out the program. Dialysis centers are required to have a QAPI plan in place under the Centers for Medicare & Medicaid Services conditions for coverage. The focus of the program is on reducing errors, preventive health care, and improving health outcomes. The centers must use data to compare performance with other facilities. Centers must collect data and prioritize and implement improvement projects.
In all cases (unless the patient is not able to respond), patients should be asked how they want to be addressed. Some people prefer to be called by their first names, whereas others, especially older adults, may be offended. Unless a patient's partner is introduced as a wife or husband, one shouldn't assume the two are married. Even if they are married, it is possible that they do not use the same last name. The technician should always introduce himself/herself to new patients.
If a dialysis center uses electronic charting, the technician should share his/her password with no one. All staff members who are authorized to access the electronic health record of a patient or patients should have their own passwords. Access to the records is tracked electronically according to the person's password. Under no circumstances should a staff member access the records of a patient to whom the person is not providing care because this is a Health Insurance Portability and Accountability Act of 1996 violation.
