DISCONTINUATION OF DIALYSIS

POLICY: When Patient's request termination of their dialysis treatment early due to
personal reasons, they must sign a Discontinuation Form. These are witnessed by
Staff and placed in Patient's permanent record.

EQUIPMENT: Discontinuation Form

PROCEDURE:
1. Have Patient sign form and record reason for discontinuation.
2. Witness Form
3. File in Chart under Consents and Refusals.
 WAKE DIALYSIS CLINIC, INC.
DISCONTINUATION FORM
(SIGN-OFF FORM)

I, ___________________________ request to terminate my prescribed _______________ Hr.

dialysis treatment against the medical advice of my Physician early because,

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

I am taking full responsibility for any conditions that may occur due to decreasing my dialysis
time. I understand that this action on my part may be harmful to my health.

___________________________________ _____________________
Signature Patient Number

___________________________________
Witness

___________________________________
Date
 DO NOT RESUSCITATE (DNR) PATIENT PROTOCOL

POLICY: Do Not Resuscitate (DNR) Patient Protocol

In the event of a Cardiac/Respiratory arrest in a DNR Patient, no extraordinary measures (i.e.

CPR, Defibrillation, intubation) will be taken. However, the Patient is to be made as
comfortable as possible. This can be done by administering supplemental oxygen for dyspnea or
normal saline boluses for hypotension. Screens should be placed around the Patient to
provide privacy. The Physician will be notified immediately. Emergency Medical Services will be
contacted and informed of the Patient's DNR status prior to transporting to the Hospital.
 DRESSING CARE FOR SUBCLAVIAN AND PERMACATH CATHETERS

POLICY: All subclavian and permacath dressings will be changed according to the
following procedure.

EQUIPMENT: Betadine
Hydrogen Peroxide
2 - 4 x 3 gauze
Bio-occlusive dressing/or gauze dressing
tape
4 - gloves

PROCEDURE:

1. Put on gloves.
2. Remove the dirty dressing carefully, holding the catheter by the 'wings' for security.
Remove gloves and discard.
3. Put on new gloves.
4. Observe the site for redness, edema or drainage, if present report to the physician.
5. Using cotton tip applicators clean the area around the catheter with peroxide, be sure to
wipe catheter site outward (from clean to dirty).
6. Using a dry cotton tip applicator wipe in the same manner to remove all peroxide from
the skin. (Betadine and peroxide together can cause a reaction will burn the skin).
7. Clean with betadine with cotton tip applicator in the same manner as described in step
5
8. Apply a clean dressing to completely cover the entire catheter exit site. Make sure a tight
seal is formed. Tape may be used to form the seal around the dressing edges.
9. Wrap the catheter line tips with a 4 x 3 gauge and tape securely.
10. Secure the end to the patient's skin with a piece of tape.
 CALCULATING DRY WEIGHT

POLICY: All Hemodialysis Patient's Dry Weight will be

following procedure. calculated according to the

PROCEDURE:
1. Subtract the dry-weight from the pre-weight.
Ex: 165 lb.s - 160 lbs. = 5 lbs. to lose

Divide the amount of weight to lose by 2.2 to convert to kilograms.

Ex: 5 lb.s to lose (divided by ) 2.2 = 2.27 kg to lose

3. Multiply the kilograms to lose by 1000 to convert to cc's of fluid to lose.

Ex: 2.27 kg to lose x 1000 cc = 2270 cc's to lose

4. Add to the cc's to lose, the amount of Saline used to rinse back the Patient’s
blood (250 cc's) and the amount of any fluid the Patient may drink while on the
machine.
Ex: 2270 cc + 250 cc + 200 cc (cup of drink) = 2720 cc

5. The total amount of cc's to lose is the OF Goal set into the machine.
 DRY WEIGHT DETERMINATION

POLICY: Dry weight will be evaluated/determined on a continuous basis by the physician

and/or the Head Nurse.

PROCEDURE:

1. Consider changing the dry weight if the post-dialysis weight is 2 (two) pounds above or
below the listed dry weight on more than two occasions.
2. Consider changing the dry weight if the patient's blood pressure decreases significantly,
or if a very high blood pressure fails to decrease when the current listed dry weight has
been reached.
3. Consider changing the dry weight if the patient leaves with edema.
4. All changes in Dry Weight must be approved by Physician.
 OBTAINING AN ELECTROCARDIOGRAM

POLICY: All patients will have an EKG ordered every 6 months or as necessary.

1.
If no EKG machine available refer patient to hospital of choice for EKG.
2. Patient should carry a Doctor's order and instruction for the Facility to send a signed
copy of the EKG to the Unit.

1.
If EKG machine is available follow manufacturer's instructions to obtain EKG.
2.
EKG should be reviewed and signed by M.D.
 EMERGENCY TERMINATION OF HEMODIALYSIS

POLICY: Patients and Staff will have an efficient means of terminating dialysis in the event
of an emergency which requires evacuation of the dialysis unit. The following
procedure will be implemented.

PROCEDURE:

1. AT ALL TIMES each chair will have 1 clamp at side, and within reach of the patient.
2. Patient will turn off the blood pump.
3. Patient will clamp the arterial and venous blood lines with the clamps provided.
4. Patient will call for a staff member to disconnect the blood lines, or if patient is able they
should proceed with self treatment termination as previously instructed.
5. The patient will leave the dialysis unit according to the emergency evacuation plan.
6. Staff will assist all patients who are unable to perform this procedure on their own.
7. All patients will be inserviced annually regarding emergency termination procedures.
 EPOGEN

POLICY: All patients receiving EPOGEN will be reviewed and evaluated according to the
following guidelines.

INDICATIONS:

EPOGEN is to be used on patients who are symptomatically anemic with a HCT <36% deemed
medically beneficial to the patients by the Physician.

INITIATION OF EPOGEN THERAPY:

Epogen will be started at the prescribed dosage or at 100 units per kg. (rounded to the nearest
hundred) of dry body weight if no dosage is specified. Maximum initial dose is 8000u. If not
previously obtained, a Ferritin, Serum Iron, Total Iron Binding Capacity, and Fe Saturation will be
obtained. If these labs return below the parameters listed below then the patient should be placed
on Iron therapy. All patients on epogen should be receiving iron therapy either in oral or
intravenous forms, except if the Ferritin is greater than 1000 mg. All patients with Ferritin
< 300 will be started on IV Iron unless contraindicated.

Ferritin < 1000

TIBC < 200 ug%
Serum Fe < 40 ug%
Transferrin sat < 30%

CONTRAINDICATIONS:

WHEN NOT TO GIVE EPOGEN:

1. Known hypersensitivity to mammalian cell-derived products.

2. Known hypersensitivity to Albumin.
3. If the patients diastolic blood pressure is greater than 110 at scheduled time of
administering. Notify M.D., order may be given to give anyway.

MONITORING

During the first month of therapy hematocrit will be checked weekly. Hematocrit should
not rise > 4 points in a two week period. If hematocrit rises > 4 points adjust Epogen.

Once the Hematocrit exceeds 26% on two consecutive checks and the patient has
completed their first month of therapy, hematocrit's will then be checked monthly. As
long as the hematocrit remains stable, i.e. no decrease greater than 4 hematocrit points
during this period, then the hematocrit will continue to be checked monthly thereafter.
Monthly hematocrit's will be done via the lab. Hematocrit's done more frequently than
monthly will be spun in the dialysis unit.
 Should the hematocrit not rise and the Iron studies were normal. A serum total and B12
level should be drawn.

Should the patient show a decrease on a maintenance evaluation of greater than 4 crit
points, then the hematocrit will be checked on the next dialysis with a spun hematocrit.
Should the level be confirmed then the physician will be notified, Iron studies (Ferritin,
Serum Iron, Total Iron Binding Capacity, and Fe Saturation) drawn and stool guaiac's
checked.

All patient's not receiving Epogen or with hematocrit less than 26% and who have
completed the 1st month of Epo therapy will receive weekly hematocrit's.

MAINTENANCE THERAPY:

In general the target range for hematocrit's will be between 32% and 36%, but the actual
target range will depend upon the patient's other medical problems. Epogen dosage may
require adjustments during therapy. The following are guidelines for modification of the
Epogen dose. This may be modified by the Attending Physician.

DOSAGE GUIDELINES:

1. Hematocrit greater than 36%, hold Epogen.

2. Hematocrit between 34% and 36% decrease dose by 25%.
3. Hematocrit between 31% and 34%. No change in dosage.
4. Hematocrit between 28% and 31%, increase previous dosage by 25%.
5. Hematocrit less than 28%, repeat iron studies (Ferritin, Serum Iron, Total Iron
Binding Capacity, and Fe Saturation), stool guaiac, increase dose by 25%.
6. When on hold Restart Epogen when Hematocrit is < = 34% at 75% of the
previous dose.
7. Do not increase over 10,000 units unless directed by a Physician. Minimum dose
is 1000 Units.

MEDICATION PREPARATION:

1. DO NOT SHAKE MEDICATION !!!!

2. Inspect for particulate matter and discoloration prior to administration, if so DO
NOT USE.
3. Use aseptic technique in administration.
4. DO NOT administer in conjunction with other drug preparations.
5. Give IV push with hemodialysis at the end of the treatment.
6. Give SQ for peritoneal dialysis patients.
7. Store medication in refrigerator at 2-3 degrees C.
NURSING DOCUMENTATION:

Epogen therapy will be documented on the Flow Sheet. The Nurse´s initials will indicate
the Epogen has been given. When Epogen is being held, (blood pressure or HCT greater
than 36% etc.), this will be noted on the Flow Sheet as well. All patients with
hematocrits < 34 should be on Epogen therapy unless contraindicated.
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 CARE OF THE ARTERIO-VENOUS FISTULA

POLICY: To provide for and establish the proper care of and assessment of the A-V
fistula.The following procedure will be used.
MAIN OBJECTIVES:

1. To prevent excess bleeding, henatoma formation, or hemorrhage from the access.

2.
To prevent infection of the fistula and sepsis.
3. To maintain the fistula's proper functioning.

A fistula is the surgical communication of an artery and vein usually in the forearm (can be
most anywhere). The arterial flow of blood into the vein causes the vein to enlarge and
allows large bore needles to be stuck into the vein for hemodialysis.

CARE:

1. Do not remove the dressing for 4-6 hours.

2. Check for a bruit at least two times daily. More often is okay.
3. If bleeding, remove dressing and find source of bleeding. Apply direct pressure, but not
enough pressure to stop the bruit. If unable to stop bleeding call the physician.
4. Before every hemodialysis, wash entire access arm with soap and water, then dry arm
thoroughly.
5. After every treatment and after dressing applied, make sure a bruit can be felt and heard.
If unable to hear bruit, loosen dressing. If still unable to hear then notify nurse or
physician.
6. If venipuncture sites or incision line looks infected, notify physician immediately.
7. Do not wear tight, restricting clothing or jewelry on access arm.

AT END OF DIALYSIS TREATMENT:

1. Make sure clamp holds enough pressure so as to not allow seepage of blood. If extra
pressure if needed, hold manual pressure. (BLOOD IS A PRECIOUS COMMODITY TO
WASTE, SO BE ALERT!!!)

POST DIALYSIS CARE:

Each patient will leave the dialysis unit with band-aids and a dressing over needle
puncture site. If it begins to bleed, apply firm pressure for 15 minutes or until bleeding
stops, apply a clean dry dressing. If unable to control bleeding, call physician.