Ask A Hemodialysis Nurse (Questions about how to become one of us)

[madwife2002, BSN, RN]

Hi I am a HD nurse with experience in PD and knowledge of HHD plus Transplant

I have over 14 years Renal experience, 4 years OB/GYN and 9 years Tele

In this forum we often see questions asked about dialysis nursing and what it is like.

I would love to answer any questions about my profession and if I don't know the answer I will find out!

In dialysis nursing we have a statement that we like to share

"you either love it, or you Hate it-there is no in-between"

[idodialysis]

I love it! 25 years experience in acutes, chronic, Pd, staff, manager. Would never do anything else!

[jdub6]

Oh good, renal/dialysis is my weak spot for sure. I have tons of questions...trying to think of what I need to know the most...

1. Can you describe the dialysis procedure, what you do when the patient arrives (assume outpatient unless you don't know about that) until you send them off

2. What is ultrafiltration and why/for whom is it used?

3. How do you access an AVF? What type of needle do you need? Is there a difference between the venous and arterial access equipment? Are the venous/arterial access points all in the same place each time and if so what landmarks do you use? What are things that would be indications of problems, reasons not to use a fistula or to stop using it, etc.? What would you see in a fistula that is clotted? Any considerations for the first time you use a new fistula?

4. What do you dialysis nurses consider to be the best/easiest form of access to use (which type of catheter, fistula, etc) and which type or protocol of dialysis is best and easiest for you and the pt?

5. When people refer to arterial and venous ports/needles for dialysis, and when we see what I think of as a typical dialysis cath with two lumens, usually one red cap and one blue, are those lumens or (or needles for a fistula) actually one in a vein and one in an artery? My impression is that fistulas are mixed arterial/venous blood. Honestly, I don't know exactly where the catheters end. Do the red and blue caps indicate arterial and venous, as in other parts of medicine? And, again, does the arterial port/line actually end in an artery, or a vein?

6. Can you explain how you use the catheters i.e. do you flush them prior to access and if so with what, which port do the inbound and outbound/return lines go to? After use, how do you flush the lines?

You started this thread so I'm hoping you are ready for this:) if not or if you don't understand my questions because of how weird the wording is no worries. I'm sure at this point my lack of knowledge has been proven. I guess dialysis is one of a few specialties that you can go through an entire career and really know almost nothing about it unless you have done it. I appreciate you volunteering your experience.

[madwife2002, BSN, RN]

QUOTE=jdub6;8720120]Oh good, renal/dialysis is my weak spot for sure. I have tons of questions...trying to think of what I need to know the most...

1. Can you describe the dialysis procedure, what you do when the patient arrives (assume outpatient unless you don't know about that) until you send them off

This is a huge question, one that takes about 6 hours from start to finish-When a patient comes to treatment you would do vital signs, the RN would do head to toe assessment looking for signs of fluid overload, they would be weighed and the target amount of fluid calculated. Arm if fistula is used would be cleaned and needles inserted, pt's prescription would be dialed into the dialysis machine and then the lines would be connected and dialysis commenced. Pt should be monitored every 30 mins vital signs taken, access site visualized at all times. Once tx has finished the patient is disconnected from machine, needles are pulled, access is held until hemostasis occurs, then the sites are covered with either a bandaid or gauze. Pts vital signs and weight is taken and pt is discharged home.

2. What is ultrafiltration and why/for whom is it used?

Ultrafiltration is defined as controlled fluid removal by manipulation of hydrostatic pressure. Ultrafiltration in dialysis is the removal of sodium and water from the blood. Dialysis patients have ultrafiltration; some of the patients need more fluid removal than other patients.

3. How do you access an AVF? What type of needle do you need? Is there a difference between the venous and arterial access equipment? Are the venous/arterial access points all in the same place each time and if so what landmarks do you use? What are things that would be indications of problems, reasons not to use a fistula or to stop using it, etc.? What would you see in a fistula that is clotted? Any considerations for the first time you use a new fistula?

You access an AVF with fistula needles; there are different size needles used on average a 15 gauge needle is used. Needles have blue and red wings for venous and arterial identification. Where you place the needles depend on what method of cannulation is being used. Each treatment the AVF should be examined looking for signs of infection, feeling the AVF for thrill and listened to the AVF for the bruit. If there is no thrill or bruit the fistula should not be accessed as absence of these could indicate the fistula is clotted. Lots of considerations for first use of fistula-experience technician, one needle, size 17 gauge needle, lower blood flow rate.

4. What do you dialysis nurses consider to be the best/easiest form of access to use (which type of catheter, fistula, etc) and which type or protocol of dialysis is best and easiest for you and the pt?

The best access without question is the Fistula. I don't understand what you mean about protocol

5. When people refer to arterial and venous ports/needles for dialysis, and when we see what I think of as a typical dialysis cath with two lumens, usually one red cap and one blue, are those lumens or (or needles for a fistula) actually one in a vein and one in an artery? My impression is that fistulas are mixed arterial/venous blood. Honestly, I don't know exactly where the catheters end. Do the red and blue caps indicate arterial and venous, as in other parts of medicine? And, again, does the arterial port/line actually end in an artery, or a vein?

Catheters end in the heart. Red and Blue in dialysis indicate venous and arterial

6. Can you explain how you use the catheters i.e. do you flush them prior to access and if so with what, which port do the inbound and outbound/return lines go to? After use, how do you flush the lines?

There is a whole process for using catheters, and accessing catheters. Many steps are involved, what in particular do you want to know about accessing them although it may differ from company to company. In bound and outbound lines are really called venous and arterial lines. The venous side of the catheter attaches to the venous line and the arterial-to-arterial line. The arterial line takes the blood out of the body to the dialyzer (kidney) and the venous line returns the cleaner blood to the body. After use you flush the lines with Normal Saline

[jdub6]

Thank you! And very impressive summary of the whole procedure (#1) :) I apologize for the confusing questions, again, I really know next to nothing about dialysis. Less complicated question: it is my understanding that all, or at least most, dialysis pts have fluid removed as part of the standard procedure, as you said in my ? about ultrafiltration. What is confusing me is recently I have seen progress boss with statements such as "pt went to dialysis but was unable to tolerate it and required ultrafiltration" or "pt received dialysis but continued to have xyz imbalance and required ultrafiltration." For these pts the d/c summary will often say something like "received dialysis with ultrafiltration" as though the ultrafiltration is sort of a fancy add-on. But from what you are saying, if I am reading it correctly, ultrafiltration is just the word for the way fluid is removed during dialysis, which is part of the routine procedure for many (most? All?) pts. So why is it suddenly being described as though it is something extra; actually the tone of most of the notes is that the pt required ultrafiltration due to being gravely ill with poor response to dialysis. Incidentally, I did not ever see this term mentioned in any notes until the last 6-12 months. Soooo...is this just a word for part of your normal procedure? Or is it something extra and unusual?

Also quick question: what makes a fistula needle different from others (aside from the very large gauge)? (I.e.: Huber needles are distinguished by the bend, they are non-coring which is necessary to maintain the integrity of the port)

And speaking of needles....you said you flush the caths with saline...(I assume you flush the fistula with saline before deaccessing?) I have always been told that one of the reasons we non-dialysis folks are never ever to use a dialysis cath except in a code is that they are filled with potent anticoagulent at an exact volume depending on cath length/size that must be removed prior to use, and when the caths have been used in codes or hospice (rarely) I have always seen them draw a large waste prior to use for this reason. Is this true?

I do understand that the red/arterial line returns "cleaned" blood, hence the term arterial. What has always confused me is whether that arterial line ends in an actual artery, like an arterial line for bp monitoring? One reason I ask is that occasionally in hospice if we are desperate we use a dialysis cath to give comfort meds if the pt is actively dying, needs the meds badly and has absolutely no alternative access. Most of us draw a big waste (see above) and only use the blue line for this,with the rationale that you only give meds through venous access and never arterial. But I am getting the feeling that they would both actually be safe to use for this, that in dialysis you distinguish between venous/arterial for removal/return and actually probably do give some meds/lytes/fluid thru the arterial side. Am I correct that they are both basically central (mixed) venous/atrial access?

You asked what I wanted to know about accessing the caths. I assume that you remove the cap and clean the end using sterile technique and alcohol like any central line. As above, do you then draw a waste, or just flush? And then is it as simple as hooking up the lines from the machine to the cath, again like a central line? You said there are a lot of steps so do you do anything that is not done when accessing and connecting a central line to an IV infusion?

Again feel free to ignore if you are bored or if I am just beyond help:) Honestly this has been my one weak spot that I have been very curious about. You have inspired me to ask all my burning questions.

EDIT: honestly, I really am a moderately experienced, competent nurse and I really have a lot of clinical knowledge about most subjects. Except this one. But, please don't take this as a reflection of my overall understanding of clinical subjects. Yikes!

[jdub6]

I was browsing some of the other dialysis threads and now have one more question: I know dialysis pts can have serious problems/intolerance during treatment and several people have mentioned the importance of "knowing when things are going wrong." So, what are the big problems that pts have during dialysis and, if it's not something common like hypotension, how do you identify them? You said vitals q30 min...are pts also/ever on cardiac monitors? (I'm thinking ectopy with electrolyte shifts...just a theory). What interventions do you do when someone is having s complication, and what can't you do in the clinic/when do you have to send them out?

Someone also mentioned grafts, which I understand are artificial "veins" grafted into the pts arm onto...their real veins? Vein and artery? What is it grafted on to? From feeling them in people it seems like they just have one tube in there...do you access that the same way as a fistula? How would you know if it was clotted since it has no bruit/thrill...flush the needles after access and see if it works?

Again, thank you!

[AcuteHD]

madwife certainly did a fine job, but I would like to add a few points also.

2. What is ultrafiltration and why/for whom is it used?

There are two functions of what is commonly cally dialysis. One is actually dialysis which is the "cleaning" of the blood, and the other is ultrafiltration which is removal of excess fluid. During a treatment the machine can be set to do either or both, depending on the need of the pt.

4. What do you dialysis nurses consider to be the best/easiest form of access to use (which type of catheter, fistula, etc) and which type or protocol of dialysis is best and easiest for you and the pt?

Strictly addressing the ease of access between fistula v. catheter, the fistula is easier for the outpatient nurse because the tech usually does it. If comparing a good fistula to a good cath, I would say the fistula is easier to access. If comparing a difficult fistula to a difficult cath, then it really just depends.

5. When people refer to arterial and venous ports/needles for dialysis, and when we see what I think of as a typical dialysis cath with two lumens, usually one red cap and one blue, are those lumens or (or needles for a fistula) actually one in a vein and one in an artery? My impression is that fistulas are mixed arterial/venous blood. Honestly, I don't know exactly where the catheters end. Do the red and blue caps indicate arterial and venous, as in other parts of medicine? And, again, does the arterial port/line actually end in an artery, or a vein?

This is a great question. The red lumen is taking dirty blood away from the heart as arteries do and the clean blood is returnd to the heart via the blue lumen as veins do. That is why it's refered to as arterial and venous, not that they are in seperate vessels. Think of red as dirty and blue as clean and that will be true for blood flow and dialysate flow.

6. Can you explain how you use the catheters i.e. do you flush them prior to access and if so with what, which port do the inbound and outbound/return lines go to? After use, how do you flush the lines?

In my facility we block each lumen with heparin after each treatment then remove and waste 3 mL of blood from each lumen prior to use.

[AcuteHD]

what are the big problems that pts have during dialysis and, if it's not something common like hypotension, how do you identify them? You said vitals q30 min...are pts also/ever on cardiac monitors? (I'm thinking ectopy with electrolyte shifts...just a theory). What interventions do you do when someone is having s complication, and what can't you do in the clinic/when do you have to send them out?

Hypotension is really the big one, legs up and saline bolus. Cardiac monitor in acutes, but not in the chronic clinic (may be facility specific)

Someone also mentioned grafts, which I understand are artificial "veins" grafted into the pts arm onto...their real veins? Vein and artery? What is it grafted on to? From feeling them in people it seems like they just have one tube in there...do you access that the same way as a fistula? How would you know if it was clotted since it has no bruit/thrill...flush the needles after access and see if it works?

The graft is an artificial tubing that joins an artery to a vein, it may be straight or looped (like a U). You should still be able to feel a thrill and hear a bruit on a graft. A graft is accessed almost the same as a fistula, except that you would not use a tourniquet on a graft. On a loop graft the needles are place beside each other instead of below and above.

[madwife2002, BSN, RN]

Incenter dialysis is very different than dialysis in the hospital-ACUTEHd is answering your questions about acute dialysis beautifully

I specialize in chronic dialysis, where nine times out of ten the patients are stable-normally if they are not stable we send them into the hospital where the acute team manage their care. At this time the patients can be very unwell and need different care, the acute nurses a lot of the are dealing with hypervolemia, they may do extra treatment i.e. ultrafiltration to remove that fluid. In the hospital they monitor the patients more frequently and are able to do more frequent dialysis and ultrafiltration due to the support of the rest of the hospital team should something go wrong.

In the chronic facilities where I work we do not use a cardiac monitor-if they need this then they are in the hospital

If we are worried or concerned about a pt who is 'unstable' then they would be on more frequent assessment and data collection would be 10, 15 or 20 min intervals.

Life for the HD nurse and the techs is crazy a lot of the time in the chronic facilities and techs can be looking after 4-5 patients at a time.

Nurses can have 12-18 patients per shift and are expected to document and document on every patient every time. The state regulates the chronic facilities very carefully, the rules and regs are extremely strict.

[madwife2002, BSN, RN]

You ask where the catheter ends-It ends in the heart normally the Catheter ends in the right atrium-the tips of the catheter are staggered and are designed to separate the inflow from the outflow this helps to reduce the recalculation risk.

The risks from catheters to the patient due to the placement of the catheter are infection, blood stream infection and a huge risk of endocarditis/pericarditis and death due to sepsis.

jdub6-love your questions!!!

[Anna S, RN]

"Strictly addressing the ease of access between fistula v. catheter, the fistula is easier for the outpatient nurse because the tech usually does it. If comparing a good fistula to a good cath, I would say the fistula is easier to access. If comparing a difficult fistula to a difficult cath, then it really just depends."

At my outpt unit, we have many pts with very poor fistulas (very small, poorly developed, very crooked, full of bends, lots of stenosis).

I find that caring for these pts is a lot more time consuming, difficult for both nurse and pt, and these pts get poor dialysis adequacy from their fistulas.

I much prefer working with catheters.

At my outpt clinic, nurses function as techs running a full load of pts, plus have nursing duties.

I also do inpt acutes, w/ q 15 min charting, which must be done on paper, then entered into Epic manually. Not too difficult when doing 1 : 1 care in ICU, but can get very hard to keep up w/ the charting when running 2 pts at a time in an acutes room, especially if pts are unstable.

As far as work load, difficulty of work, and autonomy, I much prefer acutes.

As for the hours, chronics is better.

Acutes hrs can be very long, and unpredictable.

Work load is very heavy, and labor intensive in chronics, but hours are generally routine.

[Twinmom06, ASN, APN]

I just started acute HD in July and I'm really liking it! I did 7 weeks in a chronic outpt clinic and now I'm starting my 3rd week in the hospital with a preceptor. So far so good!