Seeking advice regarding Ultrafiltration rates

[Foleynurse2008]

Hello All,

I am an RN of 4 years, although a new Dialysis RN (7 months now!). I currently work in chronics, in a busy, outpatient unit with 27 chairs for 2 RNs. I work in an area that has a lot of non-compliance (i.e.-very large fluid gains, missing treatments, not going to appointments, etc.), thus, determining ultrafiltration can be difficult at times since it is not always possible to achieve a patients EDW and keep them safe.

I had a pt yesterday that came in with a gain of 3.8kg. However, the pt was 6.7kg over dry weight. The pt is known for having large gains. When rounding, I noted the UFG of 4.6kg (we add 0.6 for rinseback), and asked if I could decrease it. The pt stated that they wanted to try to get the fluid off (the pt is not small nor very large), and requested that goal. I said that they may experience cramping or problems with a goal that large, however, they still insisted that they could tolerate it and requested that I put the 4.6kg as the ultrafiltration goal. I even looked back to prior treatments and noted that this was not an usually large UFG for the pt, as they had previously taken off between 3.8-5.0kg's per treatment.

The treatment went well with the exception of a bout of hypotension during treatment (BP was in the low 100's), that resolved quickly (I was unaware of this as the tech did not inform me). The pts blood pressure was stable post treatment (120's SBP), and denied any complaints post treatment. They even spent a while talking to other employees after the treatment was over.

The pt. called the unit yesterday stating that they had a seizure on the way home after treatment (pt. was not driving, takes transportation) and we "took too much fluid off". The pt said they were fine and that they did not want to go to the ER. I strongly encouraged the pt. to go to the ER which they continued to refuse. I later had a family member of the pt. calling, very upset about the seizure, insisting that we removed too much fluid. It was very stressful.

Needless to say, I am seeking clarification on how we are to determine proper fluid removal during treatment. I am finding this stressful, as I really do care for my patients. I have experience in ICU nursing and have always been told I am a very good and thorough nurse. Despite this, I am finding myself struggling with some of the stress associated with the clientele and work environment at times that it does not even compare to my previous experience. In combination with some other challenges at my job, my confidence is really starting to go down.

However, with the large fluid gains and the patients being very resistant at times when you try to decrease their goal, what can I as the nurse do? Are there any suggestions anyone has for preventing this sort of problem in the future? The doctors are aware of the pts tendency to have large fluid gains and have had numerous discussions with them about it.

Any input would be greatly appreciated as I am feeling pretty bad :-(

Thank you!

[tony55!]

Hi Foleynurse,

You were correct to look at the previous amount of fluid the pt tolerated. However, you should always follow policy. Since you are not familiar with the patient you will always be covered if you tell the patient - I can't pull that much, because it is aganist policy. If you feel like the patient needs a higher UF then you can always call the doctor and get an order. If the pateint demands more than the allowed amount you can document the patients request for extra UF, but you would still be responsibile if he/ she has an adverse event, because you should explain too the patient the reason for not being aggressive. You coud suggest they come for an extra treatment or run longer. However, you will need an order for the extra treatment and possible to run the patient longer (if no standing order).

You were correct to suggest the patient go to the ER, if he was still concerned about the seizure. As for the family, you can tell them that you tried to explain to him that you didn't want to pull the extra fluid, but they would probably still be upset. You can tell them that you monitored him during treatment, he was tolerating the fluid removal well and you appreciate them letting you know that you will make a note on his chart regarding - do not pull more than x - kg per treatment. You can talk to the doctor or charge nurse and see if this is the appropriate steps to take.

Good Luck, sounds like you will be a great dialysis nurse. Hang in

[Erikadawn RN]

If you want to remain a dialysis nurse, then please do not take blame for what you patients do. You will be burnt out very quickly. I have done chronics and acutes, we run into the same thing. I have had pts request 4 or 5 kilos of fluid off with a bp of 80/60. No, not going to do it, even though you want to go to a party tonight. If you don't agree, then I'm sorry. I understand its your treatment, but its my license. I will also call the MD to state the pts request, and it just may take him 3 hours to respond. Lol. But I'm not going to dialyze unsafely, so that you can drink more at a party.

[Foleynurse2008]

Chisca,

Thank you for your reply. That is a good point to ask the patient to remember how they felt so they can identify it in the future. I instructed him the next time I saw him that if he even felt remotely abnormal after treatment, to let us know. The patient thought the issue was "too much fluid taken off". He had previously tolerated even more removal than this before. When I questioned him about it later he said he may have gained weight (he was 6.7kg over his EDW and gained 3.8- so I just went for the 3.8)...

[Foleynurse2008]

Thank you for your reply everyone,

One of the main issues is that we don't have a policy. I've asked several people and searched the employee website for policies regarding it. If we had one that I knew of, you better believe I would follow that thing like it was my bible.

I was told by one of the nurses that worked there for several years now that our policy is not go above 1550ml/hr for our ultrafiltration rates-that equals a 6.2kg UFG if the patient is four hours! My other coworker even said that we can override that policy for certain patients or if the patient is overtly overloaded (which I still don't understand since many of our patients are). There is no set limit for total UFG.

Obviously I would never remove that much on a smaller patient, however we do have patients who have gains even bigger than that, who are smaller, or are over 350lbs, and many that are significantly over their EDW/have large fluid gains, and this is where I start becoming frustrated. We do have a couple patients that we try to give extra treatments to when able It is difficult as the unit is already very booked and we have three shifts on most days, thus making it difficult to squeeze anything in.

I really want to protect my patients and my license. It is really hard to not lose my cool at times. Perhaps my next best step would be to speak with the medical director regarding his recommendations?

Thank you everyone!

[Erikadawn RN]

The UF goal is a prescription, any changes to that must come from the Physician. Now we know that we adjust it all the time. But in a sticky or really unsure call the physician, and document very well. In my acute inpatient unit, when the goal is adjusted up or down, a prescription is entered into the computer.

[Guttercat, ASN, RN]

I wish there was a magic wand we could wave over patients' heads that would make them understand what shape their heart will be in after a year of high IDWG's.

It never fails. One day, they'll walk into the unit and their BP's are in the toilet forevermore. They don't understand why they can no longer pull 5 kg every treatment. We'll be lucky to get 2kg off. Cardio disease/failure is the leading cause of death in dialysis patients, not kidney failure.