ASHsplit cath care in LTC dialysis pt.

jnette, ASN, EMT-I · Mar 25, 2004

ktwlpn...

We have several of our patients who reside in LTC.

Regarding their caths, there is nothing LTC needs to do other to keep the area clean and dry if possible. They are flushed directly before and immediately after tx. only. We then use a heparin block in each lumen... there should be a sticker on the dressing itself describing the hep block and the ml amount in each.. and in big letters DO NOT FLUSH ! This is essential for ambulance personell, etc. that they know to NOT flush these caths... the blocks are removed at dialysis before initiating tx. (The blocks are either 10,000 or 5000 units heparin, don't want to flush that into the system.)

Other than that, LTC nurses and aides could be immensely helpful if being aware and meticulous about the dialysis patient's diet... knowing the restrictions on potassium and phosphorus... and obviously fluids. Even something like the nutritional "booster" drinks which are loaded with calcium can be detrimental.

Also being aware of newly placed grafts or fistulas in the cath patient... not using that arm for BPs, etc. You are correct in saying that the clinic's social worker should be communicating with the family or patient re any advance directives, etc.

If I can be of any help at all in answering further questions or clarifying concerns, I'll do my best to help you with these. :)

jnette, ASN, EMT-I · Mar 25, 2004

ooooooooops!

P.S. The dressings are changed at the dialysis facility... depending on the facilty protocol, most often they are changed only once a week as to reduce chance of infection. The less the area is exposed to air (and the critters it carries), the better.

Should the dressing fall off, and the cath is relatively new, then it would be beneficial to put a clean dry dressing over it until his next tx. If the cath has been in for 6 weeks or longer and the surrounding area appears clean and dry, it would not be neccessary to replace it.

osprey · Mar 25, 2004

I agree with the above person. We are fortunate with our LTC pts as before they start hemo; the social workers from the hospital and the facility speak and get alot of the things settled ( like advanced directives ) and the dietician also has spoken with the facility. We encourage them to send in the list of meds being taken every month, this way we know what they are on and they know if we need a new med started or stopped. or held pre hemo. ( like antihypertensives,nitro patches). We also do any bloodwork for them and send them the results, this way less chance of them trying to use a fistula arm by accident.

leslie :-D · Mar 25, 2004

we do the dsgs where i work; check for bruits/thrills and ensuring site is free of infection. also have a communication book that pts. bring back and forth.

ktwlpn, LPN · Mar 25, 2004

Thanks everyone...I will make sure everyone knows to NOT flush this cath.I found some literature I am printing out about the cath and will post it on my unit.The cath is in his right internal jugular so b/p's and blood draws are not a problem.He can not get into the bath or shower due to other problems at this point and the aides know to stay away from the dressing and the ports so it is not getting wet...He is also NPO and has a PEG tube so diet and fluid restrictions are not a problem..Prior to his admission only our admissions dept was involved in setting up the dialysis and that has always been a problem with our facility-our admissions people are NOT nurses and tend to miss many issues that escalate into big problems after the admission arrives...-I was expecting a packet of info from the clinic....never got anything..Someone at the clinic mentioned a communication book and my DON put the kibosh on that.I am not sure what her reasoning was other then "we have NEVER had to do anything like that-how ridiculous" although privacy would be a concern there,I think...I feel so sorry for for this fella-he has a long list of co-morbities and I think that things are going to take a turn for the worse soon....I am glad that he and his family are happy with the care he has received on my unit (I have some great cna's now) Thanks again-and jnette thanks for your offer and I will use your brain....I have picked up things over the years but dialysis is not my thing...I need all the help I can get.....

jnette, ASN, EMT-I · Mar 25, 2004

Sure thing, ktwlpn ! Glad to help any way I can. I'm just pleased to know that there are LTC nurses out there who give a hoot and take an earnest interest in knowing what they can contribute to contuing care on their end.

All too often we find that what we try so hard to accomplish at tx. goes bye -bye once they return to the nursing home. Please don't misunderstand... I am WELL aware of how overworked and understaffed these facilities are...and they do good to accomplish their own agenda, let alone begin learning added responsibilities re dialysis patients, etc.

We try to communicate often with the charge nurses at our local LTCs, and our dietician will send labs and dietary info back with the patient, but often it just doesn't get to the right people.

I've often wished I could do a bi-annual inservice at our LTCs... and establish friendly communication and cooperation, as well as provide a basic understanding of the dialysis patient's needs. I don't know how receptive they would be, considering their current workload.

But even the dietary dept. at LTCs need to better understand how important the patient's dietary restrictions are.. and from there down to the aides, so they would be able to pick up on errors in their meal trays... ah well... I continue to ponder creative ways to communicate these needs.

Thank you, ktwlpn, for your interest and concern... it is indeed refreshing. :)

ktwlpn, LPN · Mar 25, 2004

Sure thing, ktwlpn ! Glad to help any way I can. I'm just pleased to know that there are LTC nurses out there who give a hoot and take an earnest interest in knowing what they can contribute to contuing care on their end.
All too often we find that what we try so hard to accomplish at tx. goes bye -bye once they return to the nursing home. Please don't misunderstand... I am WELL aware of how overworked and understaffed these facilities are...and they do good to accomplish their own agenda, let alone begin learning added responsibilities re dialysis patients, etc.
We try to communicate often with the charge nurses at our local LTCs, and our dietician will send labs and dietary info back with the patient, but often it just doesn't get to the right people.
I've often wished I could do a bi-annual inservice at our LTCs... and establish friendly communication and cooperation, as well as provide a basic understanding of the dialysis patient's needs. I don't know how receptive they would be, considering their current workload.
But even the dietary dept. at LTCs need to better understand how important the patient's dietary restrictions are.. and from there down to the aides, so they would be able to pick up on errors in their meal trays... ah well... I continue to ponder creative ways to communicate these needs.
Thank you, ktwlpn, for your interest and concern... it is indeed refreshing. :)

I would love some inservices on this type of thing that really matters!...(safety and residents rights and such are important,too but that stuff leaves little time for other education) People are coming to us sicker and living longer and we need to know how to care for them.I try to get info from our staff development dept but they usually just copy and print out the same things I find on the 'net myself...I think I'll ask the DON tomorrow about inviting someone in to speak to us.....Right now we only have 2 dialysis resident in our 250 bed facility but that is no reason not to try to educate ourselves...I keep a folder in my desk with info pertaining to some of our residents diagnosis....It is a shame that more of my co-workers are not interested-it's all we can do sometimes to keep our heads above the water....thanks again

ktwlpn, LPN · Apr 13, 2004

OK-I requested an inservice fron the dialysis unit and was turned down.I was told that I can get all the info I need to know directly from my staff development dept.Bear in mind these nurses have been off of the floor for an average of at least 10 yrs and some have only ever worked in our LTC they sure can't tell me anything I can't find out for myself.. ......I have a question for you all now-what exactly do you see as the LTC nurse's responsibilities regarding psucho-social issues in dialysis patients? My resident is alert and minimally confused.His family has not visited the dialysis unit themselves (transportation and work seems to be a problem)

jnette, ASN, EMT-I · Apr 13, 2004

I'm so sorry that dialysis center is being so unhelpful.. what jerks. They should be GRATEFUL there are nurses out there who take an INTEREST in their patients, and in the continuum of care... sheeeeeeeeeeeeeeesh.

As far as psych-social issues, of course it is usually a chronic condition (ESRD) and the patient often has a hard time (at least initially) adjusting to the permanent change in his/her life as far as HAVING to go and be dialyzed 3X a week for the rest of his/her life. For an LTC patient, the loss of control over one's life and schedule is compounded. Throw in the dietary and fluid restrictions and some of these poor people may feel like it's all too much.

It really depends on your patient, however... those who are A&O, and in otherwise reasonably good health, enjoy life and want to CONTINUE enjoying life, and are capable of understanding that dialysis will buy them time and improve their blood and energy levels... as well as their general health status.

I find those who take an interest in their health, ask questions, and have a wholesome outlook on life even in their current condition, always fare better than those who choose to remain uneducated and/or apathetic about their condition. Of course this applies not only to the dialysis patient.

Don't know exactly how to answer your question... it is not common to have visitors at dialysis (unless just to briefly stop by to pass along a message) due to the bloodborne pathogen hazards, etc...

I don't see that the dialysis patient has any greater psych/social issues really, than any other LTC patient, for they are not limited in any way other than diet/fluids and need to protect their access arm or cath... and certainly some teaching and reassurance about why they need to dialyze always help, too.

Please let me know if you have anything more specific in mind, ktwlpn, and I'll try my best to help you out here. :)

ktwlpn, LPN · Apr 13, 2004

actually,'twas my DON whom declined my request to invite someone from the dialysis unit for an inservice- :stone The resident is going through his anger stage and complains constantly about the dialysis unit and then the family calls me.They have been invited to tour the dialysis unit and meet with the social worker there but have not done so...His complaints are real to him but greatly exaggerated (like his wait for transport back to the home,lack of attention,etc-I get the impression that he really has that staff jumping attentively but he wants his family to believe they push him in a corner and that's that until his treatment is finished ) The social service dept in our home really does not do much with psych-social support(they are too busy measuring people for orthopedic shoes and bras-that's another story) He is talking about stopping dialysis and he is being treated by our psychiatrist.The DON told me this is not my problem-and as long as his family is making the decisions for him he will go....I have been documenting what he tells us and encouraging him to talk.He feels that he has no quality of life-not an un-realistic belief for him,IMHO.......Other then encouraging the family to follow up with the social worker at dialysis what more can I do? I think the resident and his family need some support from someone....does the dialysis unit have care plan and team meetings and such like LTC does? I can't make the family seek out help but I can tell them what is available (and I'll know I have done all I can) What happens when a family and patient disagree about stopping or starting treatment ?(in this case no-one actually has guardianship or dpoa or poa-there is a spouse and children and all are not in agreement with every aspect of his care) Thanx for your help

jnette, ASN, EMT-I · Apr 13, 2004

actually,'twas my DON whom declined my request to invite someone from the dialysis unit for an inservice- :stone

:rolleyes: Geesh... that sux.

OK... the patient certainly has the right to choose whether or not to continue with dilaysis. We have a similar situation.. the patient really hates coming to dialysis and being in that chair 4 hours three times a week, but his sisters refuse to listen to him and won't let go.

But being competent, A&O, etc. means he has the right to make that decision for himself. Usually what happens is the patient and the doc have a discussion first. (the patient must specifically request .. and make it a point) ..must tell the nurses at dialysis he requests to speak with the doc re his concerns/wishes. Then the doc gets with the family and explains the patients wishes to them... CLEARLY. And they hash it out somehow... it's out of our hands after that. Usually it's between the dilalysis DON or NM, the social worker and the head nephrologist for the dilaysis unit.

If the family wishes info on how things are going at dilaysis for him, they need to makle an appt. or just stop in and see the NM/DON of the clinic... that's the only way they can satisfy their concerns. We are always open to meeting with concerned family, answering questions, and addressing their concerns. Never a problem, and I expect it would be that way at his clinic as well... ( it SHOULD be, anyway !!!)

Also, much depends on the size of the dialysis clinic he goes to. If it is one of those big ones.. like three shifts, and 50-100 patients, etc., then I can see where he would feel neglected... these huge clinics have always appeared to ME to be "assembly line" care. I could never work in one of them.

Our clinic has only 28-30 patients.. 12 chairs. We run two shifts, 10 - 12 patients per shift. And even though we stay quite busy, we do still have time to connect with our patients and fuss over them, carry on and joke with them, and make that all important contact... let them know we care and are interested in them as PEOPLE, not just patients. In the larger clinics, it's a whole different story. Sad, but true.

And yes, even our patients often whine about having to wait on their transporters, etc., but I figure hey... there is so little independence left in their lives... so little that they can actually control..(at least for those who do not drive or are in LTCs)... it's GOT to be difficult ! We're pretty good at getting around the little gripes and fussiness simply by being "family" with them. Again.. a smaller clinic can do this.

I's strongly advise the family to meet with the clinic's NM and social worker to fully discuss his care re dialysis. But if there's no POA or DPOA, etc., the patient's wishes should be heard... the clinic NM should be listening and getting with the patient's nephrologist and social worker on this !

Hope I have helped a little, ktwlpn...