TABLE 893 Key Historical Elements for Hemodialysis Patients

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Patients should be asked about their HD schedule. The majority of HD patients in the United States are on an every-other-day schedule (Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday), each session lasting approximately 4 h. Certain centers have begun using high-flux HD machines with higher blood flows, allowing shorter HD sessions. The physician should document all recent missed sessions and the patient's explanations for missing them. Such history taking may provide important clues concerning worsening medical or social issues that need to be addressed outside of the patient's chief complaint.

Dialysis patients are often quite knowledgeable concerning their dry weights and baseline laboratory test results. If the patient is not forthcoming with this data, the emergency physician can contact the HD center and ask about the dry weight, average interdialysis weight gains, and any recent HD complications. In addition, the dialysis nurses and technicians are very devoted to their patients can provide a great deal of "soft data" concerning the patient. Query the patient in detail concerning uremic symptoms as markers of inadequate HD. Finally, ask patients whether they retain their native kidneys, which can be continued sources of hypertension, infection, and nephrolithiasis.

The physical examination of HD patients should always include a careful examination of the vascular access ( Table.89-4). Remember, the vascular access is both the patient's lifeline and the Achilles' heel, complications of which are responsible for the majority of ESRD inpatient days. Flow through the access can be established by the presence of a bruit and thrill over the access site. The classic signs of infection—erythema, swelling, tenderness, and purulent discharge—are commonly limited until the infection is far advanced. The bedside Branham's sign may detect patients with CHF due to high-output fistula-related heart failure. The cardiac examination of HD patients deserves some special attention. Signs of CHF, such as peripheral edema, HJR, and JVD, may misleadingly suggest the diagnosis of fluid overload when pericardial tamponade is present. A loud cardiac murmur in HD patients may just represent increased flow secondary to anemia or the AV access. Neurologic dysfunction in HD patients is generally diffuse and nonfocal. Any findings suggestive of a focal neurologic deficit should be investigated for structural, vascular, and infectious causes. Rectal examination to detect GI bleeding is always needed.

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