New to dialysis

  1. Hello everyone!

    First let me say that this is an excellent forum. I'm very grateful that there are so many nurses out there to talk to and learn from.

    I'm a new nurse (graduated May 2002), and went directly into ICU. Intensive care is OK, but I don't think it is THE place for me. It's not that I'm not handling ICU; I feel pretty comfortable, and some days I enjoy it. In the course of my job, I get to speak to nurses who come in to dialyze the patients. It seemed interesting to me. So I took the plunge and accepted a position in an outpatient dialysis clinic. I don't actually start until the end of this month.

    I'm very open to any suggestions as to how to make the most of my orientation. Any books I should read besides the materials supplied to me in orientation?

    I'm very excited about my new position. After reading this forum for the past several months, I find it interesting that dialysis seems to be one of the few areas of nursing where the nurses are positive and like their jobs!

    Thanks for any input you can offer.
  2. Visit jmtmom profile page

    About jmtmom

    Joined: Mar '03; Posts: 18


  3. by   jnette
    Hey there !

    Yes, dialysis IS wonderful !!! Very interesting, and not quite like anything else out there.

    My only suggestion would be as I state over and over and over... to feel fulflled, and to give your patients the care and time they deserve, do attempt to find a SMALL, freestanding clinic.

    The large ones get so hectic that the turnover is unbelievable.. too much staff burnout.. not feeling like they have time with their patients, like it's an assembly line there. Not good. Try to find a clinic with 30 pts. or less.. 2 shifts per day.. or along those lines. Anything more would be hard to deal with and get very impersonal...

    Check out some of the other messages on the renal/dialysis forum. There's some good info and links (tutorials) there. If your company gives you the full 3-6 weeks classroom orientation, then a good while to learn the ropes on the floor, you shouldn't need any other materials... depends on the company and their training.

    I would advise visiting some of the clinics in your area.. both large and small.. look around, take it in, and see for yourself.
    I do know that most people either love it or hate it... no inbetweens. Good luck !
  4. by   Hellllllo Nurse
    Hello JMTmom-

    I am new to dialysis, too. I had two weeks reading materials and quizzes orientation, and I am on my 3rd week of floor orientation with a week to go.

    I agree with Jnette.

    (She had been very helpful and supportive towards me)!

    I work in a large unit with three turn-overs of pts a day, very hectic, VERY busy. I like dialysis, but would much prefer a slower, safer pace.

    I bought a book called:
    "Hemodialysis For Nurses and Dialysis Personnel"

    ISBN 0-8151-2099-0

    paper-back, 371 pages, $40. on Amazon. It has a lot more complicated math in it than you will need to know, but it does explain the theory of dialysis pretty well.

    However, it did not at all prepare me for working the floor!

    I hope you enjoy dialysis. Keep us updated on how it goes!
  5. by   jmtmom
    Thank you for your responses! Yes, I gathered from the previous posts that smaller clinics are better for employee satisfaction. Unfortunately, I live in a city where there is a large population of people who don't have regular access to healthcare, therefore resulting in a large population of people in kidney failure. Clinics here (Detroit) are large and busy.

    But I knew this going in. I currently work in the ICU of a large teaching hospital. So I'm pretty used to large and busy. But have no fear! I have a master plan.

    I plan to move to another state in two years (Phoenix area), and the clinics there are much smaller and more personal. I figure I'll cut my teeth here in Detroit, then "retire" to Phoenix where I'll be much less stressed.

    In the meantime, I'm glad I have my new friends here on this forum. I have some place where I can vent, and I know you'll understand what I'm complaining about.

    Again thanks for the info. I'll keep you updated.
  6. by   jnette
    Phoenix area, eh? I visit there every year in January. Mom lives NW of Phoenix, Sis lives in Tucson. Phoenix is HUGE !!!!!!!!!!!!!!

    If you go NW of there to the retirement communities (Sun City, SunCity West, etc.) you'll find the smaller clinics. I know there's one in Glendale, and a new one right outside the entrance to my Mom's retirement community SCW. I would think the ones in Phoenix itself would be quite large.

    Tucson is pretty kool as well. They might have smaller ones there. Worth looking into.

    The best to you and we're here for ya !
  7. by   jmtmom
    Hi Jnette!

    I've been doing some snooping around in the Phoenix area. As a matter of fact, I was just there visiting my brother in Mesa earlier this month. Oh the weather was sooooo perfect! Can't wait to move there

    Anyway, I looked up some clinics in Mesa, Gilbert, Tempe, Glendale, Scottsdale, etc. And you're right; they are smaller. The clinic that I hired into here in Detroit has 42 chairs, which I know is really, really big. Phoenix area clinics have something like 12 or 15 chairs, depending on the clinic.

    Here's one thing I'd like to know: what is the job of the RN versus the LPN versus the tech in dialysis clinics? When I toured my clinic, the majority of people on the floor were techs, though licensed personnel were there as well. Another thing: what makes life hard for the RN in dialysis? What makes you have a bad day?

    By the way, Jnette. Congrats on passing the boards!!! I know that's a big load off your shoulders.
  8. by   Hellllllo Nurse
    Hey JMTmom,

    I am a native Arizonan. I worked inpt hospice in Phoenix, and have done all different kinds of nursing in Tucson.

    The units may be smaller, but the population of the Phoenix metro area is now bigger that Detroit's!

    I live in Texas now. My unit is 21 chairs, 3 pt shifts a day.

    Phoenix in the summer is about as pleasant as Detroit in the winter! lol. I've experienced both a Detroit winter and Phoenix summers......

    Pinal county (just south of Maricopa county) has the largest number of diabetics per capita in the entire world. Lots of need for dialysis there. Plus, the homeless population in AZ really increases during the warm winter months, as indigent populations from all over the north and east come to AZ for the winter. Lots of underserved people without regular access to health care.

    Don't let anyone tell you it's a "dry heat". After it gets over 110, it no longer makes any difference!

    Hope you enjoy AZ and your new career in dialysis.
    Last edit by Hellllllo Nurse on Mar 17, '03
  9. by   Hellllllo Nurse
    Originally posted by jmtmom

    what is the job of the RN versus the LPN versus the tech in dialysis clinics? When I toured my clinic, the majority of people on the floor were techs, though licensed personnel were there as well. Another thing: what makes life hard for the RN in dialysis? What makes you have a bad day?

    I know that your post was addressed to Jnette, but I hope you don't mind if i resond, too.

    LPN and RN do basically the same stuff at my unit, only RNs must take turns being charge, and LPNs do not call the docs to get orders, etc. an RN must do it.

    The techs are not licensed and the nurses are ultimately responsible for the techs.

    The techs are responsible for the technical aspects of putting the pts on the machines, cannulations, getting bicarb for the machines, stocking supplies, etc. Techs where I work are trained in basic assessment, but I often find that they write "lungs clear" on everyone, no matter what. I frequently hear adventitious lung sounds in pts that techs do not hear.

    The nurses give all the meds, check that what the techs have done is correct and complete, etc. Also, lots of pts get their dialysis via "LifeSties" and caths, which can only be accessed by a nurse.
    We also write the care plans, make changes in pts treatment, etc. We do all the same stuff the techs do, plus the nursing stuff.

    The techs usually get to take their breaks, and leave on time. Often, the nurses don't.

    What makes it hard is that, at my unit anyway, it is overwhelmingly busy. Often we run without stopping from the moment we arrive, and don't get to take our breaks.
    Plus, it's difficult to oversee so many techs and pts simultaniously.

    Often, the techs have a "get 'em on, get em off and out the door" mentality about the pts.

    Many of them don't understand why when I intervene to slow blood flow rates, give NS etc. when a pt's B/P is dropping too far, too fast. They get annoyed at me, because my interventions interfear w/ their plans to move the pts along as fast as possible.

    The other day, I had just come on the floor when I found a pt w/ a HR of 38. She was diaphoretic, pale, just looked like crap.

    I assessed her, changed her dialysis settings and took the tx sheet to call the doc. He told me to send her to a cardiologist.
    I was on the phone to call the cardio's office, when a tech grabbed the tx sheet out of my hand and told me "hurry up. You're making us fall behind on charting our q half hr vitals."

    It's cluelessness like that that makes me have a bad day.

    Last edit by Hellllllo Nurse on Mar 17, '03
  10. by   jmtmom
    Hi Helllllo Nurse (and everyone)!

    I absolutely do not mind if you respond to my posts. I'm open to input from everyone. I'm glad to have the opportunity to pick the brains of you experienced nurses. Knowing you're from Arizona is icing on the cake .

    I have visited my brother in Arizona in the summer months as well, and I agree that when it's THAT hot, "dry" heat is of no comfort. When people tell me "but it's dry heat" I tell them "so is an oven". Nevertheless, I'm ready for a change in scenery. I was born and raised in Detroit, and I'm ready to experience some place else. I'm the only one out of my siblings who remained in one spot. I fell in love with everything about the southwest, including the beautiful winters. I am soooo ready to give up Michigan winters. I know that the heat in Arizona is miserable as well, but I'll trade one misery for the other.

    Thanks for the info on the RN's responsibility in the dialysis clinic. The cluelessness you mentioned is absolutely amazing. It sounds like those techs wouldn't care if the patient died as long they got their vitals on time. Very sad and frustrating.

    I understand there's more autonomy with inpatient dialysis. Anyone ever do inpatient? This was available at my hospital, but I thought it would be better for me to start out in the clinic where I wouldn't be completely on my own. Once I know what I'm doing, maybe I'll feel more comfortable with inpatient. Is my thinking on the right track?
  11. by   jnette
    Hi jmtmom !

    Just got to this, so I'll add to what Hellllo has already said.

    She was on the mark as for RN/LPN/Tech duites and responsibilities. Our techs do no assessments, however, (as in lung sounds) but they do weights and vitals. They do cannulations, AND caths and cath dressing changes as well. We don't use Lifesites at all. Other than asessments and meds, they do everything the nurses do...(including careplans, progress notes, etc.) The LPNs do everything the RNs do exept hang blood, take and write Dr. orders, and charge.. as Helllllo already said. The RNs must sign after the LPN.

    Our LPNs are tops ! They really know their stuff, and have been at this longer than most RNs there.

    EVERYBODY does the other stuff... setting up/tearing down machines, bicarb, supplies, etc. We only have one tech now ( I was the other for the past 6 years) , so we can't ask our little guy to do it all, and he's a big help to all of us. Even our DON takes her turn doing bicarb and water duties and pitches in on the floor every chance she gets.

    I guess we're pretty fortunate.. we all work well together and look for ways to help each other out.. look out for one another.

    Our patients all laugh and say they've never been anywhere to see staff fight over wanting to DO the work instead of fighting over who's NOT doing their work!

    Yep, yep, Ariz. would be ideal... often thought of doing the "snowbird" thing there. Especially as my one and only sibling lives in Tucson, and Mom in SCW. Maybe do half a year at our clinic here, and half a year as a temp in a clinic there within the same company. It's a thought.. see what time will bring.

    Well, keep us posted on how you make out !

    Oh ! I do know several nurses who do "acute" (in hospital) dialysis on call. I do know they make more that way and have more autonomy. They seem to like it pretty well. But I prefer the consistent contact with my patients.. you really do get attached.

    OK, I'm outta here ! Catch ya later !
  12. by   Allaroundnurse
    I work in a small rural chronic unit is Louisiana. Yes smaller is better. My unit runs on M/W/F and we have 2 shifts. As you can expect I am the only nurse. I have 3 excellent techs and a unit secretary. I do all of the nursing: Charge, Administrative and MD Rounds. In LA only RN's can assess. Our company only uses RN's because of this. Again small is better because you get to know your patients so that when something is going wrong you can spot it early. You also get to know how they respond to Epo, Zemplar etc. We have one doc who teaches when he rounds to help with making decisions like who needs B/P med changes and what to change it to and why. It is great to have that kind of knowledge and it helps to not have to call the doc all the time with questions. It makes his and my life easier.
  13. by   jmtmom
    Hello everyone!

    Well, the big day is getting closer. I start my new job in dialysis on 3/31. My last scheduled day in the ICU is 3/29. I haven't completely resigned from the ICU, I'll stay contingent for a while to pick up some extra money and keep my skills up. However, I have a feeling that working in this large dialysis clinic will drain all of my energy, and won't have any left for ICU. Oh well.

    Any advice on how to make the most of my orientation? Anyone want to tell me "make sure you do this" or "make sure you never do this"?

    Hellllo nurse, I know you're new to dialysis as well. How's it going for you. What, if anything, is overwhelming you?

    Is success as matter of good organization? Or is it something else. In the ICU, organization is good, but a good knowledge base and excellent assessment skills are better. Is it difficult to learn the machines? I've had some experience running CVVHD machines on my unit, and I enjoyed it (when it worked right).
  14. by   Hellllllo Nurse
    Hey JMtMom,

    Well, I am officially done w/ my orientation. I am going on a trip in the am, and will be on my own when I return to work in a week!
    But, there is always someone around to help, so thankfully, I won't be totally on my own.

    I think getting to know the machines is about the hardest part. Also, it's hard to think sometimes w/ all the noise. My unit is very noisy.
    Understanding if a pt's EDW (estimated dry weight) is really accurate for them, takes some good assessment and thinking. Not really hard to do, but there is a learning curve to it.
    Here is my list of "always" and "nevers"---

    Never leave your pt when you are returning blood.

    Never leave your pt when you are just starting their tx.

    Never allow a pt's access to be covered by a blanket, etc.
    It must always be visible.

    Always remember to double clamp your saline.

    Always check your clamps- Is what should be clamped really clamped? Is what should be unclamped really unclamped?

    Organization and time mgmt is important, as it is always is.
    An example-
    If you have several cath pts who need their dsgs changed, get them on the machines and have their tx going first, then go back and do the dsg changes after everyone is already on tx.

    When taking a pt's needles out, have a sharps container w/ you. A couple of times, I've pulled a needle out, I am holding pressure on the site w/ one hand, and realize I don't have a sharps container w/ me. I have a bloody needle in one hand and am holding pressure on a site w/ the other.... So, I've had to call out for a co-worker to bring me a sharps container.

    At my unit, only Hep B pos pts are in isolation. We have HIV pos and Hep C pos pts, whom are not dialyzed in isolation. Always treat all pts as if they were pos- Always wear your gloves, apron and face sheild. Sounds basic, but I am surprised at how many of my coworkers I see not wearing their face sheilds. There is a lot of blood in dialysis work.

    I had dialyzed one pt w/ LifeSites several times before I learned he is Hep C pos. I'm glad I always wear my PPE! (personal protective equip).

    Another nurse was taking him off yesterday. She didn't wear her face sheild, and some of his blood splattered all over. Luckily, it didn't get on her face.

    As a nurse, I am used to always feeling competant and knowledgable about what I'm doing.

    Well....dialysis is so different and there is so much to learn, I've been feeling like a real novice.

    My ADON tells me that she's had several ICU nurses quit before completing their orientation. She told me the reason for this is that ICU nurses are so used to reacting fast, and knowing exactly what to do- and then they start dialysis and don't know what to do when something happens, and it throws them.

    When I told her a couple of times in my orientation that I was feeling overwhelmed with it all, she told me that it is perfectly normal and par for the course for a new dialysis nurse.

    I had a pt this week throwing up during tx. Another nurse told me this is normal for this pt. Well, I checked, and he was eating potato chips during his tx. Had them hid in his blanket, lol. Did some teaching w/ him, re: K+, Na+, and eating when nauseated!

    Had a pt this week, B/P kept dropping during tx. Questioned him and he told me his nurse at the nursing home insisted he take his am B/P med.

    I called, and asked them to note it in his chart and MAR that dialysis pts (generally) are not to take any meds that have an anti-hypertensive effect before dialysis tx. This is really important for dialysis pts.

    Well, I envy you moving to AZ. I left AZ about two years ago. I really miss my home state!

    I hope you enjoy your new job in dialysis. I know that I am really excited about learning this specialty.
    I really needed a change in my career, and I think that dialysis nursing was the right choice for me.