New Grad RN-DROWNING in Dialysis- Help Needed!

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I am a new grad RN in dialysis & absolutely drowning. Very bad preceptorship hasn't made it easier. My biggest problem is time management. How do I perform pre-TX assessment on 9 patients and put on 1-3 patients per shift? Also, take off those 1-3 patients and do post-assessments on those 9 patients, plus do the same pre-TX routine with the next shift coming in?

One clinic was a little easier, in that we could document a little later. But another clinic says you need to get all the documentation in right away.

I feel like it is impossible to do an accurate assessment on 9 patients within such a short time. Anything less feels irresponsible or unethical.

Advice from successful dialysis nurses would be greatly appreciated!

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Specializes in Dialysis, Facility Administrator.
I am a new grad RN in dialysis & absolutely drowning. Very bad preceptorship hasn't made it easier. My biggest problem is time management. How do I perform pre-TX assessment on 9 patients and put on 1-3 patients per shift? Also, take off those 1-3 patients and do post-assessments on those 9 patients, plus do the same pre-TX routine with the next shift coming in?

One clinic was a little easier, in that we could document a little later. But another clinic says you need to get all the documentation in right away.

I feel like it is impossible to do an accurate assessment on 9 patients within such a short time. Anything less feels irresponsible or unethical.

Advice from successful dialysis nurses would be greatly appreciated!

That's tough. Post treatment assessments are very often underdone/neglected. I honestly rely a lot on my PCT's. Sometimes a patient has been terminated and is out the door before I even get to him/her. It's truly an ethical issue. For the patients I'm putting on and taking off, it's much easier. Although I have my routine down so that their chart is completely closed out before my next shift of patients go on, it's happened that I'd "do" my assessment and chart it later.

My saving grace and biggest advantage is that we close down between shifts. We get all our patients off before we start second shift. I guess that's what makes it possible for me. At my old clinic I often had to keep my assessment in my mind, noting complications mentally, and charting it later.

If they want you to chart your assessments immediately, tell them that it is impossible when you have a shift of patients you are caring for. Yeah, I know....it won't work.

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WOW! You actually close down in between shifts? Is that company policy or just how your clinic does it? Do you close for 15 minutes? sorry, I'm so curious to see how this works! Our clinics have a revolving door, so to speak, where patients come and go.

So, without being able to close between shifts, what is your routine? I've tried doing post assessments in the last 15 minutes of the treatment- that seems to have helped at least gather the data. But then to chart all that and then to assess & put on & assess new patients? I'm failing miserably. I have no problem with charting later, but some clinics do.

It DOES seem that many post assessments are simply not being done, or perhaps the charting is done on assumptions (eg, no edema before=no edema after, no irregular lung/heart sounds before=nothing irregular after). There are patients that are out the door before we get to assess them, or we don't get their end weight. It puts the RN in a very unenviable position. Do you estimate that they took off their goal? Do you assume they didn't develop a fever or irregular breath/heart sounds? This feels so incredibly unethical to me. I'd rather just leave it blank or write "unable to obtain as patient left the tx center without notice".

Is this just how things are done in dialysis? Elsewhere?

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Specializes in Dialysis, Facility Administrator.

I do the same....the post assessment during the last few minutes they are on the machine....but with 36 patients, and often me the only one doing assessments, it's not always possible. As I said, yes, I believe it is an ethical issue. I often rely on my PCT's for vital information, and I do my best to be as accurate as I can.

This is the only clinic I've ever been to that shuts down between shifts. We have about 10min between shifts to do what we need to finish up (assuming everyone got on on time and there were not complications).

I too always had a "revolving door" type of experience. I shudder over the thought of those days. Maybe it's not so bad in a small 12 chair clinic, but I've almost always worked in large places.

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Are you the only RN responsible for 36 patients at once? Or do you have 4 shifts of 9? PCTs can provide some data- temperatire, respirations, etc - but the assessment part - pain, lung, heart - isn't that only RNs? Perhaps it is different in your state.

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Handling ethical issues is one of the hardest things. If we really stand up for what we believe in, are our jobs in jeopardy? Where do you draw the line?

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It IS hard, isn't it? There seems to be this kind of gray area. where if you know the patient well enough, it's OK. But as a new nurse, how can you possibly know them, how can you possibly get the assessments done properly & on time (since even experienced nurses don't do them)? But if I wing it like the other nurses do, how long until I get caught? Or anyone gets caught?

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That sounds like an ethical dilemma to me. It sounds like it's become expected that if it's too busy, you just let the policy and procedure slide. If policy is to do the assessment and most staff are not doing them, in the state I come from that's a reportable issue, I think. But I'm new, too, and tend to err on the side of caution. Do you think the boss knows you let the assessments go if you're too busy? Shouldn't they consider adding staff so the job can be done right? (Am I terribly naive?:dummy1:)

I've had to raise an ethical question in the past and I did it with much fear and trembling. I first asked one of the more senior staff and then asked another one. The first was curt and dismissive and the other thanked me for bringing the issue to her attention and promised to look into it. I did my research before I brought it up to make sure that it really was something that might put patients at risk, and that the way it was being done was advised against in the literature. I don't think it was ever changed, and I eventually relaxed about it myself, because our situation was kind of unique and bending the rules sort of made sense in our case (I think! I hope!). But it was a really good learning experience. I found out that I had the courage to stand up for what I felt was right even though it could have cost me. If someone is harmed by ignoring approved policies and procedures, there isn't any defense, is there? Is it worth it? What would it mean if someone got caught? (Reprimanded? Fired? Loss of license? Lawsuit?) In the case of my example, other nurses had questioned the practice in their own minds, too, but never thought to raise the issue. I found out how easy it is for unapproved or risky practices to become accepted because "everybody does it." I think we should be free enough to say, "Hey, I don't think this is right!" without fear of negative consequences.

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Specializes in Dialysis, Facility Administrator.

It is an ethical dilemma. I don't have a clear cut answer for you, I'm so sorry :( Just do the best you can.

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yep...that's what i'm doing. so much to learn as a new nurse, but wish this wasn't something i came across so soon.

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