CCHT Patient Assessment 2 — Questions and Answers
Question 1: What is the primary purpose of weighing a dialysis patient before and after each treatment?
- To monitor for weight gain from increased muscle mass
- To calculate fluid removal (UF) goal and assess post-treatment dry weight achievement (Correct answer)
- To determine if the patient is eating adequately
- To adjust EPO dosing based on body weight
Correct answer: To calculate fluid removal (UF) goal and assess post-treatment dry weight achievement
Pre- and post-dialysis weights determine fluid status: pre-dialysis weight minus dry weight equals UF goal; post-dialysis weight confirms whether target dry weight was achieved.
In ESRD patients, weight fluctuates primarily due to fluid retention between sessions. Pre-dialysis weight minus dry weight equals UF goal (fluid to remove). Post-dialysis weight should equal dry weight. If significantly higher, the patient is still fluid overloaded; if lower, the patient may be dehydrated. Scales must be calibrated and patients weighed consistently. Dry weight is reassessed regularly because body composition changes with nutritional status.
Question 2: During pre-treatment assessment, a patient reports taking a new herbal supplement for kidney health. What is the most appropriate response?
- Tell the patient herbal supplements are safe and not to worry
- Document the supplement, inform the charge nurse, and ask the patient not to take it until cleared by the nephrologist (Correct answer)
- Advise the patient that all natural supplements are safe for dialysis patients
- Ignore the information as it is not medically relevant
Correct answer: Document the supplement, inform the charge nurse, and ask the patient not to take it until cleared by the nephrologist
Many herbal supplements contain potassium, phosphorus, or nephrotoxic compounds and can interact with medications; all supplements must be reviewed by the nephrologist.
Herbal supplements can be dangerous for ESRD patients: many contain potassium (dangerous with impaired excretion), phosphorus, or compounds that accumulate without kidney clearance. Some are nephrotoxic. Drug interactions are also a concern. The technician should document the supplement name and dose, notify the charge nurse, and request a pharmacist or physician review before the patient continues taking it.
Question 3: When assessing a patient's vascular access before cannulation, which finding requires withholding cannulation and notifying the charge nurse?
- A palpable thrill extending along the fistula
- A large, firm, non-compressible hematoma directly over the intended needle sites (Correct answer)
- Mild warmth of the skin overlying the fistula
- A faint bruit heard on auscultation
Correct answer: A large, firm, non-compressible hematoma directly over the intended needle sites
A firm hematoma over the cannulation site poses a bleeding risk if needled and may indicate recent infiltration or traumatic injury requiring evaluation before proceeding.
A hematoma at the intended cannulation site requires assessment before proceeding. Needling through organized hematoma increases bleeding risk, may track along the needle path, and can obscure vessel depth. The charge nurse and possibly vascular access nurse or surgeon should evaluate the access. Document findings thoroughly. Signs of good access: palpable thrill, audible bruit, soft skin without induration, no erythema suggesting infection.
Question 4: What does a positive Tinel's sign at the wrist suggest in a long-term hemodialysis patient with an upper arm access?
- Good arterial blood flow through the fistula
- Carpal tunnel syndrome, commonly caused by beta-2 microglobulin amyloid deposits (Correct answer)
- Normal neurological function
- Early signs of vascular access stenosis
Correct answer: Carpal tunnel syndrome, commonly caused by beta-2 microglobulin amyloid deposits
Tinel's sign (tingling when tapping the carpal tunnel) suggests carpal tunnel syndrome, which is common in long-term dialysis patients due to beta-2 microglobulin amyloid deposition.
Beta-2 microglobulin (B2M) is a small protein not adequately cleared by standard dialysis membranes, accumulating over years. B2M amyloid deposits in the carpal tunnel, joints, and bones cause dialysis-related amyloidosis (DRA). Carpal tunnel syndrome from B2M deposits is common after 5 or more years on dialysis. Tinel's sign (percussion of wrist causes hand tingling) or Phalen's test suggest carpal tunnel. High-flux dialysis and online hemodiafiltration better clear B2M.
Question 5: A patient on dialysis has a serum albumin of 2.8 g/dL. What does this value indicate and why is it clinically significant?
- Normal albumin; no intervention needed
- Malnutrition with poor prognosis; requires nutritional intervention and dietary consultation (Correct answer)
- Excessive protein intake requiring dietary restriction
- Fluid overload diluting albumin levels only
Correct answer: Malnutrition with poor prognosis; requires nutritional intervention and dietary consultation
Serum albumin below 3.5 g/dL indicates malnutrition or inflammatory state, and levels below 3.0 g/dL are associated with significantly increased morbidity and mortality in dialysis patients.
Normal albumin is 3.5 to 5.0 g/dL. In dialysis patients, albumin below 3.5 g/dL signals malnutrition, chronic inflammation, or dialysis-related protein losses. Target for dialysis patients is above 4.0 g/dL. Albumin of 2.8 g/dL is a major independent predictor of mortality. Interventions: dietitian consultation, oral nutritional supplements, intradialytic parenteral nutrition (IDPN), treatment of infection/inflammation, and ensuring adequate protein intake (1.2 g/kg/day).
Question 6: During assessment, a patient's blood pressure is 185/110 mmHg pre-dialysis. What information is most important to collect before proceeding?
- Patient's dietary sodium intake from the previous day
- Current medications taken that day, compliance with antihypertensives, and comparison to baseline BP (Correct answer)
- The type of blood pressure cuff used
- Patient's most recent Kt/V value
Correct answer: Current medications taken that day, compliance with antihypertensives, and comparison to baseline BP
Determining medication compliance and baseline BP patterns helps identify whether this represents a hypertensive emergency, volume-related hypertension, or medication non-compliance requiring specific intervention.
Pre-dialysis hypertension is common and usually related to volume overload between sessions. Key assessment: (1) Did the patient take their antihypertensives? (2) Is this different from their usual pre-dialysis BP? (3) Any symptoms suggesting hypertensive urgency (headache, visual changes, chest pain)? (4) Interdialytic weight gain (fluid overload extent). Report to RN. Usually managed with dialysis itself (fluid removal reduces BP). Do not routinely give extra antihypertensives pre-dialysis as hypotension during treatment is a serious risk.
CCHT Patient Assessment 2
What is the primary purpose of weighing a dialysis patient before and after each treatment?