UF Profiling & Sodium Modelling

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    Hi! I have been a PCT for almost 3 years now. Started with Da Vita in Michigan and moved to NY where I'm now working for a privately owned clinic. I learned that there are different state laws that we have to follow here (like PCTs cannot draw their own heparins, can't put catheter patients on and we actually have stools that we could sit on!). I was told that PCTs cannot use UF profiling and sodium modelling without doc's orders. But they're really never around and our RN's are not very aggressive as far as setting UF goals for fluid overloaded patients. Most of our patients run for 3.5 to 4.5 hours with only 4 kilos as max goal even if they have gained 8-9 kilos. I was taught that I could use UF profiling and sodium modelling together to remove fluid in the old clinic I used to work for. Most of the patients back then would run for 3 hours and we could pull even up to 5 kilos at a time. So I'm left debating goals with our RN's and I don't want to seem like a know it all when I know I still have a whole lot to learn. Should I go by UF goal or UFR as far as setting their goals on the machine? Also I have found out that there are certain PCTs that have been with this company for a long long time that would mess around with their machines (when there's really nothing wrong with the machine) so that they wouldn't have as many patients at a given time (our ratio is 4:1 which of course sometimes turns out as 6:1 esp if your partner is lazy). My hubby thinks I should look for another company to work for but am now afraid that all companies here in NY would have be the same? Any comments?
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    I have been in dialysis now for 7 months and I still have questions regarding the profiling and modeling. I do see that it is so individualized and you really have to try different approaches over several TX's. I have been jotting down notes on your comments. My BIGGEST hang up is giving pt's NS. I know it is a "have to" many times, but when the reason they are there is take fluid off, I just have trouble giving it back to them! I really enjoy reading these and seeing that I am not alone at there!! Thanks for the knowledge you are all sharing with me.
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    Wow! 7-8 kilos?

    My cut off limit for extraction is 3.5 kg. Above that in special cases when: they are overloaded, it's their last dialysis day and sometimes when I am kind enough.

    I don't really do UF/Sodium profilling that much. But I have been using SU (Sequential Ultrafiltration) for overloaded pts. Done on the first hour, extraction goes from 1kg - 2kg max (though the most I did was 1.4). At this time, only fluid extraction takes place - not dialysis. The rest of the three hours (4 H here) are the combination of two. Managed to avoid cramps, low BP even if I extract more than 4 kg. But not my most preferred treatment mode also - you are deprieving the pt one hour of waste clearance. If I can afford to go for 5 hours, I might do that.

    UF profiling alternates between the rate of fluid extraction and how it allows capillary filling in between the lower UF rates. Some has gradually decline while others goes on an up/down pattern. Personally, I have not seen one patient that sees any benefit in this, so much that I disregard this method at all.

    Again, the best way to avoid all the hassles is prevention. Fluid restriction is very important. Adhering to pt's wishes for more fluid extraction will only foster bad habits and creates complications in the long run.
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    I totally agree with you bluefabian re fluid restriction. Unfortunately, the clinic that I am working for right now have real spoiled patients. And worst, my co workers let them do whatever it is they want. Some of them even run out to get the patients food and drinks (when it's not supposed to be allowed during tx!) I try to educate them as much as I can and it never fails that the response I get is "I've been doing this for 5 or so years and no one's ever said anything to me." It's now my 3rd month working for this clinic and sad to say I am getting discouraged and really thinking twice about continuing my employment with the said company. I thought that maybe I can make a difference when I first started but like I said it is pretty discouraging!
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    Most likely depends on your state and nurse practice act also as where I am it's a physician based order and treated no differently then the standard hemo orders or medication order. The only thing we determine related to profiling as nurses is to turn it off due to high b/p's and it's part of our routine standing orders to do so. It's part of the dialysis order in my state and not decided by the RN's as to how and if to use. Some facility medical directors may not object to the RN adjusting but it's not actually within our realm of practice based on the NPA for many states. It may not seem like a big deal but until you have had to give a deposition in a legal situation it can change your mind real quick.
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    I guess it all depends on where you work. I am based in a non profit community centre that runs independently without doctors. Our MO comes a few times in a month for visits and will see the need for any standing order based on the condition. Based on the observation that we see in a patient, we will seek advise from doctors as what to do. But really, it's in the guidelines and protocol as well. If it's not there, and I am not authorized to do it - I won't. Simple and clear. Not really about nurses deciding if they want to do it - it's about doing that based on needs, and with consultation with more experienced peers and our doctor as well.

    nu2dialysis,
    You are doing a great job. Just need to understand that chronic patients are hell, damn hard to educate - with their habits and pessimism. I had one patient who had undergone a minor stroke the other day and was left with left side hemiplegia. Known him very well of being very bad with fluid restriction, always asking for 3.5-4 kg extraction. I had my time of telling him to control and even refusing his request for more. Many, many times. The last time he had dialysis before the stroke, I gave him 3.5 kg and even with that he can't finish it because of hypotension. It was during the two days off that he got it, either he was really enjoying himself too much or other factors that aggravate the HPT. Now he came in whelled in, no longer able to walk and needs assistance in feeding. I asked myself this "Am I too lenient or are they being stubborn?". The complications will surely show, just a matter of when. And oh yeah, this patient was on HD for 5-7 years.

    Oh yeah, I don't really like patients eating too much during tx also. The blood reroute that goes for digestion can lead to hypotension - seen this many times already. Plus, it can also mask the fluid loss that occur - pt may be thinking that little extraction occur and demand more next time. Then the cycle goes.
    nu2dialysis likes this.
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    european regulation only allows to not more than 1L /hour. We have a patient who's a non compliant with his fluid restriction and often comes with 8-9l, what we do is we ask him to come back for certain day for ultrafiltration.Some pts are still on denial of their dse. eventhough they have this for ages. I think treat your patient individually ,you can ask your RN for dry wieght assessment for this patient and check his/her diet,obvious sign overload(edema) or maybe your pt gained weight.I work in a mother unit where we deal with chronic and acute,,its good to know and treat pt individually.Our oldest patient is 83 and been dialysing for almost 32 years.
  10. 0
    Quote from bluefabian
    Oh yeah, I don't really like patients eating too much during tx also. The blood reroute that goes for digestion can lead to hypotension - seen this many times already. Plus, it can also mask the fluid loss that occur - pt may be thinking that little extraction occur and demand more next time. Then the cycle goes.

    Oh, this just happenes to be one of my pet peeves!

    In my clinic it was absolutley verboten to eat while on the machine or in the tx. room, period! That was ONE thing I at least agreed with upper management on.

    We encouraged our pts. to eat BEFORE they came to the unit, or to bring a lunch or snack with them for when they left. All our patients were informed at teh time they signed their admission paperwork that this was a unit policy strictly adhered to.

    Not only can it lead to hypotension as described by the poster above, but just think of the cross contamination !!! With so much exposure to bloodborne pathogens, who in their right mind would truly want to EAT in that environment?

    They might as well be eating in the bathroom stalls!!!

    No way.
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    So true Jnette! If only I had the support of management on this one
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    I work for a Fresenius Acute unit, and we have a fair amount of lattitude (but of course, our docs come in to see each and every patient on each and every dialysis treatment).

    The docs write for a certain goal, but we are free to challenge that goal if we can give a valid reason (lungs are wet, increased edema, or up or down based on blood pressures for instance). Our max we can take off (actual UF, not including prime and rinseback or boluses) is 6 liters -- anything more than that requires a doctor's order.

    We frequently use sodium modeling with the docs that are friendly to that concept -- we have one group that orders it routinely, and one group that is split (you just have to get to know them individually). We profile most patients with a goal over 2L. Again, this is up to the nurse -- some like it, some don't. The doctors have all blessed the practice and tend to back us up as long as we are getting good results and not causing the patient harm -- even when we aren't able to meet the original goal.

    One thing I would like to point out: We have noticed that on our Fresenius 2008K machines, when we use the profiling (profile 4) it ALWAYS pulls off more fluid than what it says on the screen -- by AT LEAST 1/2 L. Some of the nurses have a problem with this, but I myself like it because knowing that it is actually taking off a bit more means that I can be generous in my rinseback and ensure the patient gets as many RBCs as possible back, and I needent worry about having to give a bolus every now and then that I didn't anticipate at the beginning of the treatment.

    ANNA is a supporter of the profiling -- they had an article in the journal last year.

    Hope this helps.




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