BONENT CHT cheat sheet

Adequacy targets for thrice-weekly hemodialysis: single-pool Kt/V of at least 1.2 and urea reduction ratio (URR) of at least 65%.

URR (%) = (pre-dialysis BUN − post-dialysis BUN) ÷ pre-dialysis BUN × 100; blood for post-BUN is drawn using the slow-flow or stop-pump method per facility protocol.

Ultrafiltration goal = pre-treatment weight − established target (dry) weight; the fluid removal rate is generally kept below 13 mL/kg/hour to limit intradialytic hypotension and cramping.

Intradialytic hypotension: systolic fall of 20 mmHg or more, or mean arterial pressure fall of 10 mmHg or more, with symptoms; immediate actions are stop UF, Trendelenburg position, and a 100–250 mL normal saline bolus per order.

Dialysis disequilibrium syndrome results from rapid urea clearance producing cerebral edema; risk is highest in the first treatments and is reduced by lower blood flow and shorter initial sessions.

Mature AV fistula criteria (rule of sixes): blood flow at least 600 mL/min, diameter at least 6 mm, depth no more than 6 mm, and usable roughly 6 weeks after creation.

Typical dialysate prescriptions: potassium 1–4 mEq/L (2K most common), calcium 2.5 or 3.0 mEq/L, bicarbonate 32–39 mEq/L, sodium 137–140 mEq/L, temperature 37 °C.

Pre-treatment assessment parameters: weight, blood pressure, temperature, access thrill/bruit, bleeding risk, edema, lung sounds, and symptoms since the last session.

Standard treatment train order: sediment (particulate) prefilter → water softener → carbon tanks (two in series) → reverse osmosis → storage/loop → ultrafilters at point of use.

Total chlorine/chloramine in product water must not exceed 0.1 mg/L; carbon tanks are tested before each shift with a DPD-type test because chloramine causes hemolysis.

AAMI/ISO limits for product water used to prepare dialysate: bacteria ≤100 CFU/mL and endotoxin <0.25 EU/mL; for final dialysate: ≤200 CFU/mL and <2 EU/mL.

Water softener works by sodium-for-calcium/magnesium ion exchange; hardness is tested daily and the resin is regenerated with brine on a timed or volumetric schedule.

Reverse osmosis removes roughly 90–99% of dissolved ions, bacteria, and endotoxins; percent rejection and product water conductivity are the routine performance indicators.

Deionization removes dissolved ions but not bacteria or endotoxin, and an exhausted DI bed can release previously adsorbed ions and organic material into the product water.

The distribution loop must be free of dead legs, have continuous recirculation, and be disinfected on a defined schedule; cultures and endotoxin testing of water and dialysate are performed at least monthly.

Dialysate conductivity is normally about 13–15 mS/cm at 25 °C (equivalent to roughly 140 mEq/L sodium); it is verified with an independent meter, not the machine display alone.

Ultrafiltration rate is governed by the dialyzer's Kuf (mL/hour per mmHg): UF rate = Kuf × transmembrane pressure; a rising TMP at a fixed UF goal signals falling membrane permeability.

High TMP or high venous pressure alarms commonly indicate clotting in the dialyzer fibers, a kinked or clotted line, or inadequate dialysate flow.

Air detector alarm: the blood pump stops automatically; the lines are clamped and blood is not returned to the patient until the air is removed.

Blood leak detector alarm: dialysate flow and UF stop; the treatment is not resumed and blood is not reinfused until the leak is evaluated per policy.

Dialyzer reuse acceptance criterion: total cell volume (TCV) must remain at least 80% of the original measured value; below that, the dialyzer is discarded.

Dialysate temperature is set near 37 °C (acceptable range roughly 35–39 °C); cold dialysate causes shivering and vasoconstriction, overheated dialysate risks hemolysis.

Before each treatment the machine undergoes a self-test and alarm check, the extracorporeal circuit is primed with saline to remove air and sterilant, and residual disinfectant is verified absent.

Standard precautions apply to every patient: hand hygiene, gloves for all blood or body-fluid contact, gown/face protection when splash is likely, and safe sharps handling.

Hepatitis B surface antigen–positive patients require a separate room and dedicated machine; hepatitis C and HIV patients do not require isolation when standard precautions are used.

Blood spill decontamination: 1:100 dilution of household bleach (about 500–600 ppm available chlorine) for routine blood spills; 1:10 dilution for gross contamination or large volume spills.

Hepatitis B vaccination is offered to all susceptible patients and staff; post-vaccination anti-HBs testing confirms immunity.

Needlestick or mucosal exposure: wash the site with soap and water (do not squeeze or use caustic agents), report immediately, and initiate HIV post-exposure prophylaxis ideally within 2 hours and no later than 72 hours.

Hand hygiene is performed before patient contact, after glove removal, after contact with blood or contaminated equipment, and between patients.

Catheter care uses a mask for both patient and staff during connection and disconnection, antiseptic hub disinfection, and sterile technique to prevent catheter-related bloodstream infection.

Sharps are discarded immediately into puncture-resistant containers at the point of use; containers are replaced when three-quarters full.

The certified hemodialysis technician delivers treatment under the supervision of a registered nurse or nephrologist and does not independently diagnose, prescribe, or alter a dialysis prescription.

When an order or machine condition appears unsafe, the decision rule is: stop, clarify with the supervising RN or physician, document the concern, and escalate up the chain of command.

Documentation must be objective, timed, and contemporaneous; late entries record the actual event time plus the time of entry, and records are never altered or backdated.

Protected health information is released only for treatment, payment, or health care operations, or with patient authorization, consistent with HIPAA.

Informed consent requires that the patient receive the risks, benefits, and alternatives; a competent patient's refusal is documented and honored.

Certification such as BONENT CHT is time-limited (4-year cycle) and maintained through continuing education or re-examination.

Professional boundaries prohibit accepting gifts of significant value, discussing one patient's information with another, and providing care while impaired.

CMS Conditions for Coverage for ESRD facilities are codified at 42 CFR Part 494 and set minimum health, safety, and quality requirements surveyed by state agencies.

A survey deficiency requires a written plan of correction stating the corrective action, the responsible person, and the completion date.

OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030) mandates a written exposure control plan, engineering controls, PPE, training, and free hepatitis B vaccination for at-risk staff.

AAMI/ISO standards relevant to practice: water treatment (RD62/ISO 23500 series), dialysate (RD52), and dialyzer reprocessing (RD47).

CDC recommendations for preventing infections in dialysis patients address vascular access care, vaccination, water quality, and staff education.

Adult learning principles for patient teaching: short sessions, plain language, teach-back to confirm understanding, and skill demonstration with return demonstration.

KDOQI and KDIGO publish evidence-based clinical practice guidelines used to set adequacy, anemia, bone-mineral, and vascular access targets.