Advice about going into hemodialysis

westieluv · Jul 13, 2014

Typical day in my chronic unit:

Arrive at 5 AM.

Check water with a tech before we can let patients in.

Unlock the doors and start taking patients back to the treatment floor based on their scheduled start times. If a patient who is supposed to be on at 6::30 AM arrives before a patient who is supposed to be on at 6:00 AM, you take the 6 AM person back first and the 6:30 person will often begin complaining because they were there first.

Weigh the patients one by one. Walk them to their chairs. Assess them for any cardiac or respiratory problems or signs of excessive fluid gain. Compare the weight they came in at to their dry weight (not the weight they left at the previous time, dry weight is what it is estimated they would weigh if they had healthy kidneys and normal fluid excretion) and see if you can safely remove enough for them to get to their dry weight. Some patients watch their fluids and always achieve their dry weight, while others are very noncompliant and never achieve their dry weight. A lot of patients will tell you how much they feel that they can take off without becoming symptomatic, and they become upset if you try for more. You have to be realistic when setting the goal. If someone comes in 6 kg above their dry weight, you are not going to be removing 6 kg of fluid, you just do the best that you can without them becoming symptomatic (hypotension, muscle cramping, nausea and vomiting).

After you help the techs put on the first shift of patients and have assessed and charted on each patient (we normally have about ten patients per nurse per shift, sometimes more, sometimes a few less) you pass meds and protein supplements to each patient as ordered. It is then time to do any of the following: round with a doctor if he comes in, complete patient care plans, do foot checks on your diabetic patients, check labs and call abnormals to the doctor, and monitor the treatments. BP's are checked and charted on every half hour and it is very important not to miss them.

After about 3-4 hours, you start helping to take the first shift of patients off of their treatments, do post-treatment vitals, call the transportation companies for patients who depend on them to take them home, and start setting up for the next shift. The two shifts will overlap some, so you will be helping to take patients off and doing pre-treatment assessments on other patients at the same time. Patients must be weighed on their way out the door so that you have an accurate picture of how much fluid was removed.

If patients don't show up (and there are quite a few noncompliant chronic renal patients who miss treatments frequently) and don't call to let you know why they aren't coming, you need to try to get a hold of them and see why they aren't there and document it.

That's basically it, repeat until the last shift of patients leave or you get to go home, whichever comes first.

kdunurse · Jul 16, 2014

I've been working in a hospital-based dialysis unit for a couple of years. We're different from other units in that we don't do acutes (inpatients) and chronics (outpatients) separately, which has its advantages and disadvantages. Most hospital based dialysis centers will have a separate acute unit, and you will do either acutes or chronics, but not both, in a shift. In an 8 hour shift, you will probably have 6-8 chronic patients (or more, depending on your role), because most dialysis treatments take 3-4 hours.

A chronic unit will be divided up into pods of 3-4 stations (chairs) each. Many units will have a tech for each pod, who are responsible for getting treatments started and ended, as well as machine care. Treatment times will be scheduled so that patients in the same pod ideally aren't arriving or leaving at the same time. The pace is very fast during turnover (when one shift leaves and the next arrives) so you need to be very organized and good at multitasking. There is also a lot of documentation, both with the treatments themselves, and the patients generally (education, lab values, orders and so on). Reimbursement is closely tied to documentation, so there is a lot of pressure to make sure your paperwork is done correctly.

There is a very steep learning curve with dialysis - it is very specialized, and very different than most other types of nursing. I only had 6 weeks of orientation, but the big two dialysis companies offer a much longer orientation. It takes a few months to become familiar with the machine, let alone the rest of it. One other thing to consider - if you are doing any sort of inpatient treatments, you will be expected to take call once you have enough experience. This entails going in to do treatments on acutely ill patients (often in the ICU) when the dialysis unit is closed. You will be the only one there who knows dialysis, so you need to be part plumber, part biomedical technician, and part nurse. This may happen the night before you are expected to work at 0630, or on a holiday. It's not for everybody, for sure.

Mrsjonesgilbert · Jul 17, 2014

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