Home Dialysis Interest Group HEALTHCARE TEAM TOOL DEFINITIONS FOR STATUS & TARGET WEIGHT BALANCED EXCESS DEFICIT Illustrations provided by: 1
BALANCE OF THE HOME HEMODIALYSIS PATIENT Dialysis Weight** **Target Weight: The target weight is defined as the level below which further fluid removal would produce hypotension, muscle cramps, nausea and vomiting. In other words, the lowest weight a patient can tolerate without the development of symptoms. Target weights may change over time. Indications that you may have gained weight or body mass and should increase the target weight: You have been eating more than usual. Your blood pressure is lower than usual, especially after dialysis and does not improve throughout the day. You experience low blood pressure or cramps during dialysis. Your heart rate is fast, over 100 beats per minute. You experience fatigue, weakness and dizziness. If you experience these signs and symptoms you may be too dry. It is time to increase your target weight. Ensure you communicate this change with your dialysis nurse. Indications that you have lost weight or body mass and should decrease your target weight: You are experiencing shortness of breath You have swelling You have been eating less. You have been exercising more. Your blood pressure is higher than usual If you experience these signs and symptoms you may be too wet (too much water) and it may be time to decrease your target weight. Ensure you communicate this change with your dialysis nurse. 2
EUVOLEMIA / BALANCED STATUS / CORRECT TARGET WEIGHT exists when there is a homeostatic balance of fluid volume in proportion to the lean body mass / fat. BALANCED Assessment Signs & Symptoms weight stable blood pressure within normal range for individual no postural drop related to fluid volume normal non-laboured respirations lung fields clear to auscultation good skin turgor minimal edema mucus membranes moist (see exceptions to the rule) Possible Causes Actions Outcome Intake body mass stable, no mass lost or gained - target weight adjusted to compensate for loss or gain of mass weight maintenance of dietary prescription (food and fluid) Output appropriate fluid removal during dialysis none present Assessment Steps BP (sitting and standing if possible) Pulse (sitting and standing) Check weight (if possible) Respirations assess fluid balance positive reinforcement and encouragement continued maintenance of euvolemic state Precipitating Factors Individual adherence to plan of care 3
DEFICIT This condition exists when the individual does not have enough fluid in his/her circulation. DEFICIT Assessment Signs & Symptoms low blood pressure pulse weakness dizziness - cold and clammy - yawning or restless with change in respirations - raspy voice - ear popping fatigue muscle cramps poor skin turgor may be below target weight increased thirst Nausea & vomiting Urge for bowel mov t Abdominal cramps headache blurred vision increased blood pump alarms Possible Causes inadequate fluid intake a gain in lean body mass / fat without adjustment of target weight. excessive ultrafiltration incorrect UF programming vomiting, diarrhea, excessive sweating i.e. exercise / weather / sauna incorrect weight Measurement - fluid removal plan not based on weight / BP assessment Rule Out Confounding Factors: coexisting medical diagnoses inappropriate use of antihypertensive medications Sepsis Interdialytic hypertension related to residual renal function Actions to achieve Euvolemia Ongoing Assessment Steps BP (sitting and standing if possible) Pulse (sitting and standing) Check weight (if possible, if symptomatic instruct individual to lie down) Respirations - review previous dialysis logs for patterns and trends if patient is at target weight, the target weight may need to be increased assess oral intake offer the patient a salty drink or broth or normal saline during dialysis refer to Dietition assess for possible causes of increased fluid loss review method of weighing assess calibration of UF pump on dialysis machine assess accuracy of scales - assess timing of blood pressure medications Precipitating Factors review individuals medical history ( if individual requires immediate attention, send to ER and notify home unit) 4
EXCESS This condition exists when the individual has too much fluid in his/her circulation. EXCESS Assessment Signs & Symptoms may be above target weight higher than usual blood pressure (note: BP may be variable with cardiac patients) shortness of breath crackles and wheezing in lungs c/o headache edema (facial, eye, fingers, sacral region, legs, ankles or feet) - review previous dialysis logs for patterns and trends Possible Causes excessive fluid intake salty food intake loss of lean body mass / fat without adjustment of target weight inadequate ultrafiltration incorrect UF programming urine output incorrect weight Measurement fluid removal plan not based on weight / BP assessment Rule Out Confounding Factors: patients with cardiac disease may have lower tolerance for fluid excess Actions to achieve Euvolemia On-going Assessment Steps BP (sitting and standing if possible) Pulse (sitting and standing) Check weight if patient is at target weight and symptomatic, the target weight may need adjustment to be decreased Respirations - review previous dialysis logs for patterns and trends instruct individual to monitor and reduce fluid and salt intake assess nutritional status and reasons for weight loss refer to Dietition review changes in volume of urine output -increase Hemodialysis session to manage symptoms and drop target weight review method of Weighing assess calibration of UF pump on dialysis machine assess accuracy of scales Precipitating Factors review cardiac history ( if individual requires immediate attention, send to ER and notify home unit) 5
Exceptions to the Rule: The assessment of an individual s fluid status may be impacted by other factors such as cardiac disease, hypoalbuminemia, medications, and infections. 1. Cardiac disease Individuals with cardiac impairment may have low baseline blood pressure despite fluid volume excess. This may impact on decision making for ultrafiltration. 2. Hypoalbuminemia Hypoalbuminemia is a condition when the serum albumin is low. The assessment of fluid volume status can become challenging since hypoalbuminemia is associated with increased edema, with a low serum albumin, fluid accumulates in the interstitial space. The problem persists as fluid cannot be mobilized easily into the circulation. This results in low circulatory volume with fluid accumulation in the tissues. These individuals may present with a low or normal baseline blood pressure and edema even when at their target weight. The cause of this state is poor protein intake, or being unable to replenish protein losses. Advice can be sought from the renal dietitian for alternate protein sources. 3. Medications Peripheral edema may be associated with certain medication regimens and not related to fluid volume excess e.g. nifedipine, amlodipine, thiazolidinediones's (TZD's) CHECK WITH PHARMACY 4. Infections will cause low blood pressure and fatigue. Blood pressure related to sepsis may not respond to the use of saline bolus. 5. Diabetes The stiff, non- contracting, tone of a diabetic s blood vessels may result in overall lower blood pressures. 6