Dialysis nurses: Please teach me!

  1. I am a CCU nurse who has worked with patients being dialysed at the bedside. I have some questions about outpatient dialysis.

    1. Are the solutions pre-mixed or does the nurse have to adjust to the needs of the individual patient?

    2. How much critical thinking and intervention is needed now? I was told that the equipment and practice of dialysis has become very routine. That is not what I see in acute care. My patients often become hypotensive, need colloids, electrolytes, and so on.

    3. What assessments do you have to make before, during, and after administering medications?

    4. What do you think is safe staffing? How should techs and/or LVN, LPN, and unlicensed assistants be utilized?
    5. Is there always a doctor present?

    THANK YOU to anyone who goes to the trouble to answer!
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  2. 17 Comments

  3. by   ageless
    Of course, I can only speak for my program... I work acutes.. chronic is much more ridgidly structured.

    1. The dialysate bath consists of an acid and a HCO3. (Acid contains the electrolytes) Baths in the acute setting, are patient specific and change per patient per day according to the daily lab values. One starts with a a few standard solutions and adusts them accordingly. We have standing orders to make adjustments. For instance, If a patient is acidotic, I would run a higher bicarb, or if the the patient has ca++ or K+ issues, I would also adjust my bath. These adjustments can be made through machine settings and/or the solution. Our nurses also decide the ultrafiltration goal based on our assessment.

    2. Chronic dialysis can become routine, acute is anything but routine. Standing orders are endless with multiple choices for the same problem. No two dialysis nurses will run the patient the same way, we all have our individual theories... our Nephrologists respect that and give us lots of latitude....and of course some runs are easier than others. My team is responsible for their own drips, and sometimes vent settings. We also assists out docs with line and catheter placements

    3. Our assessments cover all body systems. We also serve in a coordinator role making sure that all consults and disciplines are "on the same sheet of music" so to speak. By the way, I love PA and A lines! I make adjustments as the patient conditions changes during the run.

    4.Safe staffing in acutes...hmmm.
    depends on the acuity of the patient. I spend most of my time in ICU and ER where it is usually 1:1 and occasionally 2:1. We also have a 10 bed acute stepdown unit in one large hospital where in-patient "stable" patients can be transported. Per ten patients..2 RNs and two techs. In my program, techs can't cannulate, give any meds, or take patients on or off the machine. Some places allow this. Our Docs do not. Our program covers 7 hospitals with 6 nephrologists and 8 acute nurses. (We also have 9 chronic centers in our program.) I may go to 2-3 hospitals in a day. The RNs become credentialed in each hospital and care for the patient and the equipment. Thank goodness for our bio-med for harder to fix mechanical problems. (each RN also carries tools).

    5.Sometimes a doc is present, sometimes a doc is present for part of the run and sometimes not at all. We all carry private phones/pagers for communication. I can only take orders from a nephrologists which sometimes puts me "in the middle" between physicians. Many times, I have been the only one in the whole building that knows what I am doing...LOL

    Please tell me about your acute dialysis program!

    .
    Last edit by ageless on Jun 18, '02
  4. by   TELEpathicRN
    My acute program sounds similar to yours. We cover 4 hospitals
    and 8 nephrologists. We have all RN staff, no techs. We don't have any chronic units in our program. We are assigned to which ever hospital needs us, and then may have to go finish the day at another hospital. We are not supposed to titrate drips, supposed to have the pts nurse do it", but it just depends on the dialysis nurse and the ICU nurse. All of our remote treatments are 1:1. We adjust the baths and UF goals per labs/assessments.
  5. by   ageless
    We also incorporate plasmapheresis, C.V.V.H.D., and PD in our acute program. Is that similar also?
  6. by   TELEpathicRN
    No thank god!!! I really would love to learn plasmapheresis and
    CVVHD, but we don't do them. Most all our pts that come in the hospital with ARF start with HD and then they are presented with the "treatment options" and alot of them choose PD. In our city, we have a chronic PD unit that the pts go to and get the education to do PD and then they are the unit that follows the pts progress. If a PD pt comes in the hospital, the floor nurses are trained or either the pt does it.

    I would love to learn more about plasmapheresis, could you tell me more?? Is it similar to HD??

    Tell me more!! Talk to ya later
  7. by   pickledpepperRN
    Thank you all!
    I work in a unit where at least one of my patients is on dialysis almost every day. Many have told me the frequent interventions were uncommon in the outpatient setting.
    Others said they felt the same things and the dialysis nurses were just as busy. I admire the technical and assessment skills of dialysis nurses. Thank you for posting!
  8. by   ageless
    http://hemato.unice.fr/sanderson/pe.htm
    http://www.mdausa.org/publications/fa-plasmaph.html

    I posted some sites for you to see, and will add some bullets.

    Plasmapheresis requires 1:1. So many different things can go wrong. There is no bath, a cell separator is used instead of a kidney, and requires no water filtration system. It takes about 45 minutes just to prime the system. Each treatment takes about 2 hours. Two pumps are used, one like a hemo pump and the other to move the plasma.
    CA++ levels (CA++ is always replaced) and ACT are monitored every half hour.
  9. by   TELEpathicRN
    COOL!!!! THanks for the info! Maybe we will do that one day.
  10. by   nursefiggy
    I work in an out pt clinic. Everyone gets the same bath and it is done by the reuse techs. We don't have jugs on the machines; the dialysate comes through lines in the walls.
    It can be very hectic. Some days I have to do very little interventions other than all the bp support. Some days my pts are very sick and keep me very busy. I work with sub acute pts. The ratio is three to one nurse. The other sections it is 4 to one tech.
    As far as meds, we make no assessments for the routine ones (Epo, Zemplar, etc) only the PRN meds like Tylenol (po) or Bendadryl, Phenergan, etc. And then the reglar regulations apply.
    We do not always have a dr present but most of the time we do. There is usually a "fellow"close by. Our nephrologists have particular days they round and sometimes just pop in. We are on the same campus as Vanderbilt so there is a doc that can be there in 10 minutes if need be or we can send a pt to the ED in no time.
  11. by   jnette
    Our outpt. unit is small ( 12 stations) so we do mix our own bicarb dailey in a big mixer, and fill the large jugs which are carried to the machines. The acid jugs we fill from barrels which are pumped to lines and spigots upstairs.. we fill these also. This job is shared amongst all of us.. nurses and techs alike.

    Our staffing ratio is four pts. to one staff... be it nurse or tech. We only have one tech, so there are always nurses on hand. Our LPNs do everything the RN does with the exception of charge and taking phone orders. We have standing orders and algorythms we follow for epo dosing and zemplar, ferrilecit, etc. as well as adjusting weights and heparin boluses and/or pumps.

    Our nephrologist is over an hour away up in Roanoke, so he comes down monthly. So no, we do NOT have a doc on hand except for once a month. But he knows us well and we work well together, he allows us to use our own judgement and he is always available for us to call if we need him. We have placed first in numerous area and regional awards re our facility's URR's and labs... so I guess we're doing something right ! Except for our tech, everyone has been there since before I came aboard, and that's been 6 years now ... so we all have much invested in our patients... we are like family. Dialysis even in a SMALL clinic is extremely physically demanding (due to inadequate staffing issues as per usual... the corporate greed thing again )
    and very hectic. Yet the day flies by and we have great fun with our patients.

    It is challenging and interesting to work with the hypotension issues... juggling the adjustment of dry weights, use of mannitol or NS, etc.... after a few weeks of trial and error we usually come to some individualized resolution for each patient which is gratifying.

    Many factors play into ESRD and dialysis... very interesting, challenging, rewarding when the patient is motivated and compliant (some take a year or more to become so, some never do)... and ALWAYS very sad when we lose one, as we have been together for a good while....
  12. by   pickledpepperRN
    Thank you Jnette!
  13. by   GTS
    Originally posted by ageless
    Thank goodness for our bio-med for harder to fix mechanical problems. (each RN also carries tools)
    Is this a compliment?? Lol. And here I thought y'all just talked bad about us all day....

    BTW, I say thank goodness for nurses who are willing to help us out with the smaller, common problems. Nice to hear someone that will help instead of hearing"That's not my job". I don't think some of y'all realize how much we really do appreciate the help. There's nothing worse than driving 30 miles to a hospital, walking through the hospital to find a machine (god knows where it is sometimes) to change a bicarb wand o-ring or something like that because "it's my job". Thanks! :kiss
  14. by   jnette
    Originally posted by GTS
    Is this a compliment?? Lol. And here I thought y'all just talked bad about us all day....

    BTW, I say thank goodness for nurses who are willing to help us out with the smaller, common problems. Nice to hear someone that will help instead of hearing"That's not my job". I don't think some of y'all realize how much we really do appreciate the help. There's nothing worse than driving 30 miles to a hospital, walking through the hospital to find a machine (god knows where it is sometimes) to change a bicarb wand o-ring or something like that because "it's my job". Thanks! :kiss

    Whoa !!! That WOULD be the pits !!! We do keep up with most of the "little stuff" like O-rings, batteries, spare parts, etc. at our clinic, and we're ALL well trained in the water system, and all the dailey checks and double-checks, LALs, cultures, etc. We do all of that. We no longer have reuse, so that's one headache gone, but there's still plenty of "technical knowhow" we have to constantly be updated and inserviced on...

    Yeh, we appreciate our machine techs... you, too, are over worked and spread too thin. So what else is new, eh?

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