Since there is no longer a RN present to do pre and post assessments when one goes into a home program, how do assessments differ from in-center?
I do the same thing as in-centre: check BP sitting and standing, temperature, weight. I have to keep a log of these, although, to be honest, nobody has ever asked to see them.
I have to do BP, Temp, weight and tell them how much I am taking off of hubby Ralph. I then call into our center so they can add it to their records. They watch us all night via internet. In the am I do the same thing, telling them BP’s, BVP, Fluid removed, temp and weight.
Pat
I have to chart b/p standing and sitting, temp, weight and pulse both pre and post as well as during treatment (pulse, b/p, pressures, fluid removed etc). I also have to daily chart my heparin load, blood flow rates, u/f rates, etc., these I turn in each month at my appointment and email them with my billing info at the end of the month.
Interesting how we all report differently.
I think if you ever do home dialysis you will soon understand that you end up knowing your body real well and have the freedom to change u/f rates, adjust dry weight, etc.
As I said before, I keep daily logs for pre-treatment and post-treatment, as well as during treatment. Every half hour, when the machine takes my BP, I log that plus heparin remaining in the heparin syringe, arterial and venous pressures, TMP, UF rate, blood flow, dialysate flow, conductivity and dialysate temperature. There is no internet monitoring, and nobody asks to see the logs on a regular basis, but I guess they could refer to them if I had any problems or an emergency. I bring them along to my monthly clinic appointment. I personally find them useful to have a history of my dry weight and BP. I can vary my dry weight on my own to some extent, also blood flow. I find I feel better starting with a lower blood flow, say 325, for a while, and then I up it to 400. I check and log the total volume of blood that has gone through after treatment.
I no longer do a lot of logging during treatment, usually only once, as everything goes pretty smoothly these days. I don’t use the b/p on the machine as it makes so many mistakes and constantly takes 2-3 checks to give me my b/p and I have a very sensitive arm, so I use my own cuff.
I don’t have anyone monitoring my treatments either, but I do have a nurse I can call 24/7 if there are any problems, I’ve only had to call a couple of times with minor machine problems.
I agree that having the records would be good, but luckily I have a pretty good memory and there really hasn’t been much flucuation.
Pierre writes:
I do the same thing as in-centre: check BP sitting and standing, temperature, weight. I have to keep a log of these, although, to be honest, nobody has ever asked to see them.
Someone is not doing their job. In-center, I find corners are cut on assessment, too. This is considered a violation of regulations.
Funny you should mention the BP being taken twice. My machine was doing that too. almost since the day I got it home. I found it very annoying (and useless really, since on the second inflation, the BP reading is bound to be wrong anyway from the arm being engorged with blood) – but not enough to complain about it, since I was used to the machines at the dialysis centre doing that too. On Friday, it finally gave up the ghost somehow. It kept reinflating each time until it gave me an error saying the BP cuff could not deflate (paraphrasing here, as I don’t remember the exact wording of the alarm message). I used my own BP machine during that treatment, but I gave them a call and a tech came Saturday morning to replace the BP module in the machine with a new one. It’s a very quick and easy replacement. The new module worked fine, but it’s only been one treatment since then (yesterday).
Generally, I find BP measurement in the dialysis world almost laughable - not even close to being in conformity with the proper way of measuring blood pressure, and almost guaranteed to result in inaccurate measurements (usually higher readings).
Pierre
Cathy writes:
I have to chart b/p standing and sitting, temp, weight and pulse both pre and post as well as during treatment (pulse, b/p, pressures, fluid removed etc). I also have to daily chart my heparin load, blood flow rates, u/f rates, etc., these I turn in each month at my appointment and email them with my billing info at the end of the month.
>>What is the point of assessment info if your doctor/team is only looking at it once a month? My understanding, and the way I use, is assessment is to prepare me for the current tx and each successive tx. Much can, and does change from one tx to the next, let alone in a month.
Cathy writes:
I think if you ever do home dialysis you will soon understand that you end up knowing your body real well and have the freedom to change u/f rates, adjust dry weight, etc.
>>I have assessed dw and goal for years in-center with doctors’ blessings.
Jane,
Home hemodialysis patients and/or their helpers are more in charge of their treatment. Not that everyone who dialyzes in-centre is passive about it (I certainly wasn’t), but, when you do your own hemodialysis, by interest and training, you are better equipped to understand what is going on and when it’s necessary to call the nurse. A nurse is always just a phone call away, 24 hours/7 days. If the post-treatment info shows anything unusual, like an unusually high or low BP, a high temperature, a post-treatment weight that is out of whack with the UF goal that was programmed, we know enough to call. We probably end up following ourselves a lot more attentively than what the staff in dialysis centres do, since we are our one and only patient.
It’s no different than PD patients doing their own dialysis. They only go to clinic once a month too, and in between, they call if there’s a problem.
Overall, I would say I get more “interested” attention as a home hemodialysis patient now than I did when I was dialyzing in-centre. I think this is because the nephrologist and nurses who run the program take a special interest in it succeeding.
Cathy writes:
I no longer do a lot of logging during treatment, usually only once, as everything goes pretty smoothly these days.
>>Do you mean that your unit does not require you to do logging?
Cathy writes:
I don’t use the b/p on the machine as it makes so many mistakes and constantly takes 2-3 checks to give me my b/p and I have a very sensitive arm, so I use my own cuff.
>> I also do not find the bp apparatus of the machine to be accurate. The cuff loosens up and then the bps read too high. Have you found a cuff that works well? I would like to purchase one that is easy to use and reliable.
Cathy writes:
I agree that having the records would be good, but luckily I have a pretty good memory and there really hasn’t been much flucuation.
>> This is something that I would not like to leave to memory. I like having a complete record so I can refer back to it, if need be, in black and white.
Pierre writes:
Generally, I find BP measurement in the dialysis world almost laughable - not even close to being in conformity with the proper way of measuring blood pressure, and almost guaranteed to result in inaccurate measurements (usually higher readings). s:
>>It seems that the machine blood pressure device in-center is just for staff conveinience to comply with govt. regs. and not in the best interest of patients. Hard to believe something as important as bp measurement is not efficient and CMS overlooks.
Jane, if you read my earlier post I said I DO keep records of every treatment, what I don’t do is take a lot of readings and loggings during every treatment, usually just once, unless something is unusual. (Pierre had noted he logs every half hour, I was simply saying I log during the first 30-60 minutes and then not again unless something is amiss) In the beginning I did log more often but since everything is stable I find it unmeaningful and my center agrees, my b/p and pressures remain stable so the only difference is amount removed and I log total amount so it too doesn’t really matter.
With regard to b/p cuffs, the Omron is generally considered to be the best, that is the one I use.
I do have a monthly summary with b/ps, pulse rates, temps, weights etc., but do not copy the daily reports I turn into my center as my pressures remain pretty stable and nothing else other than daily u/f rates really vary by much.
Jane, you will find that you will learn a lot more, like following pressures, being able to “feel” if your b/p, temp etc. are off, you just become much more aware of everything. You will only find this out if you actually do home hemo, I’m not sure you are really looking or simply being a devil’s advocate on this board.
With regard to the point of assessment, it is so WE know what is going on and WE know when to contact our center because something is amiss. The center reviews these reports to ascertain that we are doing a good job in analysis and reporting anything to them that we should be reporting. You are NOT correct that much changes, actually the only change from day to day is fluid removal. If something changes then it IS to be immediately reported, remember when we are doing home hemo we become the tech and nurse and have the responsibility of knowing what we are doing.
Well, to be fare, during dialysis, they are mostly taking regular readings of BP to ensure the patient’s BP isn’t falling too low. They don’t need an absolutely accurate reading for that.
Automated BP machines really should never be used to make treatment decisions, ie. prescribe medication. The only reliable instrument for that is a properly-calibrated sphygmanometer - in other words, a manual BP measurement device used by a person with adequate hearing and trained/certified in how to properly measure blood pressure.
Unfortunately, for patients who are on dialysis, there is a tendency to rely only on the automated device all the time just because it’s there. As far as making treatment decisions regarding BP, measuring BP at dialysis isn’t exactly the most accurate setting. I mean, you’re not really at rest, the arm may not be at heart level, you’ve had maybe 2-3 litres of fluid removed from you in a short period, etc., plus, I don’t really have confidence in the calibration of those machines. They see such heavy use, for one thing, and the cuff may be too small or too big for the patient (nobody checks this, but this will affect the measurement).
Personally, I’ve always felt that the nurses should periodically check the BP using a manual cuff, and they certainly should do it manually during the monthly clinic appointment - but most of the time, they use a machine for that too. Same thing at pre-dialysis clinic appointments. To compound the problem, everything we know about BP from research over the past century involves otherwise healthy people. We don’t really know what the optimal BP is for dialysis patients. There is some sketchy evidence that what is optimal for “normal” people may be too low for hemodialysis patients. They are really just guessing.
Cathy writes:
Jane, if you read my earlier post I said I DO keep records of every treatment, what I don’t do is take a lot of readings and loggings during every treatment, usually just once, unless something is unusual. (Pierre had noted he logs every half hour, I was simply saying I log during the first 30-60 minutes and then not again unless something is amiss) In the beginning I did log more often but since everything is stable I find it unmeaningful and my center agrees, my b/p and pressures remain stable so the only difference is amount removed and I log total amount so it too doesn’t really matter…I do have a monthly summary with b/ps, pulse rates, temps, weights etc., but do not copy the daily reports I turn into my center as my pressures remain pretty stable and nothing else other than daily u/f rates really vary by much.
>> It is interesting that you are not required to log every 30 minutes as is done in in-center units. Can anyone confirm if logging every 30 min. is a govt. regulation or just unit protocol?
I watch all the data on my machine and go back over it later via my run sheets. I’ve made a practice of doing this to review the tx as in-center there are more errors than one carefully doing one’s own tx in a home program would have. We’ve already addressed inaccurate blood pressures. Yes, I can feel when my bp is doing something, but often I can’t accurately confirm what it’s doing as the bp readings are off. This is an example of how patients are prevented from knowing accurately what their body is doing. Everytime it occurs to me how to get a more accurate idea of the tx., I take a step up. So, in this instance it will mean getting my own bp device.
The same thing applys to HR (I kept having an ending pulse of as much as 140 something at one time. With different conditions, my pulse came into normal range. Never got an answer as to why this was happening to me. My sheet held the record, however, so I could refer to it to see what was going on and how to correct. BFR can easily be set wrong by a tech who is in a rush ( my body quickly tells me if the BFR is set too high and later I learned to watch this setting as well as all the others). Early on I had high neg. art. pressures. This was before I knew what a high art neg pressure meant. So, again, the run sheet has been an assessment tool for me. The run sheet reveals the entire tx. Was the goal set properly? 1.3 or 3.1 removed due to tech error? And in-center the machines frequently come out of calibration, so it is good to have the run sheet from which to review. These are just a few examples-there are more.
For some there is less fluctuation from tx to tx. For others, just a small difference in weight gain or loss can make a big difference.
Cathy writes:
Jane, you will find that you will learn a lot more, like following pressures, being able to “feel” if your b/p, temp etc. are off, you just become much more aware of everything. You will only find this out if you actually do home hemo, I’m not sure you are really looking or simply being a devil’s advocate on this board.
>>These things are not learned only through being in home hemo. One can be just as aware in-center. It depends on how well one is educated on the tx. Personally, I have no interest in playing devil’s advocate. I am for accurate dialysis education and would love to see professionals take a greater role in contributing to this board.
…
Jane my point is in MY treatments my arterial and venous pressures vary only by about 10 points no more no less, so charting is meaningless. My u/f rate stays the same throughout the treatment unless I change it, and I set it originally so a mistake won’t happen and charting wouldn’t help, I would certainly notice on the first charting. My b/p is stable and I do check it more frequently, just don’t chart it unless it isn’t “usual”, something my clinic should see (which hasn’t happened since my first week on dialysis during training).
I don’t vary dialysate flow or b/f nor do I change my heparin amounts, so it is unnecessary to constantly recheck these things.
I’ve never been in a unit but would guess I would prefer to have it checked more often, although I think I would know what the settings should be and I would verify that they are correct. Since I am the only one using my machine it should be correct for some things like sodium and bath prescription, something a center must change for each patient.
You seem so negative about home dialysis units and I have found them to be wonderful, extremely responsible and caring, know me and my treatment extremely well, very responsive if I need any assistance and probably more knowledgeable than most dialysis units since most if not all are r/ns with many years of experience, we don’t deal with techs (except for machine maintenance and repairs). I see a dietician and social worker each month, and I have blood work as needed, monthly or as often as every few days if I have changed my bath or have an abnormal result.
I’m really not sure what Jane can get from “professionals” on here that informed home hemodialysis patients can’t provide in terms of how hemodialysis is done at home. These are not really questions that professionals are needed to answer. I’ve always found that patients like me learn more from other patients than from anyone else.
Cathy, I see your points exactly and am saying the same thing- that it’s not as necessary to be as vigilant about checking everything so over carefully in a home program, because home patients set up their own txs and are not affected by nurses and techs who may be prone to errors because they are rushing to put numerous patients on. It’s a much different story in-center, so the run sheet is a good record to have.
I’m not negative at all about home programs. You must of read something into my internet words that I did not say. I’m all for home programs! I agree that the home program nurses I have spoken to sound like good nurse educators and were very enthusiastic.
I am not sold yet on a particular machine or home program as I don’t have all the info I need yet to proceed. I see where some have had problems with alarms or with service and others are not clear on which modality is best for them. So, I’m just waiting until the picture comes in a little clearer since I don’t have a unit where I can try each of the modalities to see which one I like best. I have to choose a machine without getting to try it out first. This will be a new program for my area. We do not have experienced home training nurses here. So, I am still in the looking things over stage. That is why I would appreciate hearing from more professionals as to their insights on home programs.
Pierre writes:
I’m really not sure what Jane can get from “professionals” on here that informed home hemodialysis patients can’t provide in terms of how hemodialysis is done at home. These are not really questions that professionals are needed to answer. I’ve always found that patients like me learn more from other patients than from anyone else.
>> My belief is that no one knows it all. I have gotten my dialysis education from many people, both educated patients ( like you Pierre and Cathy) and professionals. Many professionals I have encountered know less than educated patients. So, I am not referring to them when I say professionals. I am referring to the professionals who really do know dialysis, stay current in their knowledge, are good educators or are involved in the invention of the various machines that are on the market for home hemo. There are angles that only patients know so I really listen intently to that, but there is knowledge that some professionals have that patients do not.
Hi Jane.
You originally asked what kind of assessments are done pre and post treatment. I think that question was amply answered early on in this thread. I don’t know what more could be said about it by anybody, lay or pro. It’s a normal part of nursing to do a “round” at specific intervals. In dialysis, as you know, they do it about every 30 minutes, and this information is logged. At the dialysis unit I used to go to, the log was actually electronic, that is, BP, etc. is automatically logged by the computer, but a nurse would come around and input his/her information into the system as well. At home, I do the same thing, but it’s not computerized. There’s not much more to it. I was trained to recognize the symptoms of various things that are relevant to hemodialysis, especially low blood pressure, infection, air embolism and hemolysis. If I get any symptoms, I know enough to take some kind of action. For example, if I start yawning, I’ll check my blood pressure. If it checks out Ok, I repeat the check after a short while. If my systolic under 110, I automatically know to infuse 200ml of saline, and check again. Before treatment, I check my BP and my temperature. If I have any sign of high temperature, I’m supposed to phone the nurse before starting treatment. So, it’s pretty simple. Most of us do the exact same kind of pre and post assessment they do in dialysis centres, and because we do it ourselves, we are probably more careful about it. Any more ominous symptoms like chest pain would prompt me to call 9-1-1 - simple as that. You don’t take chances with those kinds of things, since as a patient, we can’t really self assess chest pain.
“Assessment” sounds like a big, important word, but it just means doing the things we are already doing. We do this way more frequently than the staff at most dialysis centres, even though we may not be logging it each time.
This is all stuff you would learn during your training if you decided to go for home hemodialysis, and you would only do so if you are a relatively stable patient. As for choice of machines, well, I’ve already given my opinion about that in other threads at various times. It’s a machine, and it does dialysis. The machine is just a bunch of pumps and sensors. The main thing is that about a cup of blood is out of the body in a sterile blood circuit, and it goes through a dialyzer. All dialysis machines basically do the same thing. I don’t see how it matters that much which make it is, except for convenience issues and for reliability. Usually, the greater the convenience, the lesser the reliability, simply because the greater convenience must be achieved by having more automatic things on the machine that can go wrong. It’s like agonizing over which computer to buy. If you’re always waiting for the next model that will appear in a month, you will be waiting forever. Just do it.
Problems with the machines seem to come in clusters. I had no problems at all for almost 2 months. This past Thursday evening, my R/O (the water purification unit) broke down and I had to skip that treatment. The technicians, local employees of the hospital which operates all the major dialysis units in this city, were at my home with a replacement R/O by 9 the next morning, and I did my treatment normally later that day. During that treatment, the machine refused to take a blood pressure reading. It just kept reinflating and reinflating until it gave an alarm. I simply used my own BP machine for the rest of that treatment, but the boys from the hospital were at my place Saturday morning to replace the blood pressure module in the machine. Why were they able to fix it the very next morning, and on a Saturday at that? Simply because they are the same team of techs that service the machines at the four hospital dialysis units, two of which run 24 hours a day, 7 days a week, plus the 4 satellite units in the hinterland and all the home machines within the region. They have all the parts because my machine is identical to the machines there, and they have to be able to keep something like 200 of those machines running on a daily basis.
Based on my experience so far, I would say that easy serviceability and local-based service are the most important things to have. Other than that, as long as the machine does dialysis, I’m happy. Now, if that kind of local service were not available to me, I would still want to do daily home hemo, but I would want to be assured of reasonably quick service. From reading about other patients, it does seem like they all get pretty good service. I think this is because every organization involved in home hemodialysis is interested in making it look as good as possible.
This is just me, but I like the fact that I use the same machine as they do at the dialysis centres in my city, because anytime I end up having to dialyze there for whatever reason (this does happen), I already know how everything works and I can keep an eye on things. It’s just very empowering.