incontinent NH pts

rondafan · Aug 27, 2009

I know this is an old post but I am currently having this problem in my unit. We have a pt that arrives in a geri chair, has both legs & 1 arm amputated, has full control of bowels but cant "hold it" for long. We have a staff of 3, myself & 2 techs & a bathroom the geri chair wont fit into. So when she has to go we call the NH staff to come get her, we have a no lift policy & honestly couldnt move her if we tried. (90 kg) The NH staff has threatened to report us to state for not taking her to br & ending tx early due to soiling herself. Now what do we do?? :banghead: The other 2 NH pts we have the NH staff will come to the unit & clean up their residents & then they go back to tx, well this other one is total lift with a hoyer & in a geri chair, if I could get her to the br & assist to toilet I would but we cant even get her in there. My nurse manager & the DON of NH are really butting heads on this one right now. Copies of our policy have been sent to the NH.

Trauma Columnist · Aug 27, 2009

Have you tried a bowel retraining program? Nothing to eat/drink 2 hours prior to HD? Depends?

Sometimes, you have to realize that dialysis isn't improving quality of life and withdrawal might need to be discussed with the pt making the final choice.

**canoehead, BSN, RN** · Aug 27, 2009

Kind of an unnecessary comment. Have you ever worked in an outpatient HD unit? If you had, you would understand the frustration of having an incontinent patient in a RECLINER who probably cannot stand or be repositioned without several people, poop everywhere, no privacy curtains or nice little bath buckets with hot soapy water. Alarms, turnaround, patients wanting this and that, docs on the phone, BPs in the toilet all around the room. It's not really that HD units are "poorly" staffed, we are just not staffed for that kind of treatment on a regular basis. Having someone be incontinent on the ED gurney with supplies and help convienently nearby is a different story.

I still don't get it though. People poop, it's a fact of life, and though I understand that you shouldn't be giving a suppository and sending them out for HD sometimes accidents are going to happen. If they are incontinent they need to be cleaned up, and we're not talking a 30min treatment where you can put it off for a few minutes and do it when they get off the machines. They are going to be sitting in it for several hours, and everyone around them is dealing with the smell. If there are no curtains/no equipment/no supplies then get some. If a recliner is difficult to work with then use stretchers. Staffing is an issue on every unit, but we don't leave people to ferment in stool, we get 2-3 staff together and flip patients like pancakes but they get cleaned.

I'm not trying to put down all the HD nurses, if that has been the way dialysis has been run all along then you are doing your jobs. I strongly feel that the job needs to change and you should have the equipment and facilities to care for people when they are incontinent.

Are the HD nurses saying they would do it if they had the facilities (I could understand that), or that they don't feel it's part of their responsibilities even if they are provided with the supplies?

Sometimes, you have to realize that dialysis isn't improving quality of life and withdrawal might need to be discussed with the pt making the final choice.

Seriously? Withdraw support because they are incontinent? My mind is just boggled- look I must not be getting a key piece of this...

81Bubbles, BSN, RN · Aug 27, 2009

there are no strechers in dialysis units. There is no room for them either. If a patient required a strecher or bed they are not fit to be in the chronic setting and should be in an acute dialysis setting which is inpatient. Also we are accessing the patints blood stream and moving them around is completely unsafe if the are attached to the machine, and still relatively unsafe if they are detached form the machine temporarily (like needles flushed still in arm or saline locks on catheters). There is the risk of bleeding , infiltration, and the risk of exposing a patient to sepsis (which when they have a central line in is a HUGE risk).

Every time you rinse a patient back mid treatment you are also drastically reducing the adequacy of their dialysis treatment.

I know where we worked we had many of the NH patients NPO before tx for the day (we tried to have them in 1st shift) . Also some patients recieved Imodium pre tx as well. Along with as others had mentioned. Bowel/and Bladder traing regime's in place.

I Know personally it was something in the begining that I felt so Horrible and Cruel for but the more I learned about HD the more I realized that it wasn't mean cruel or because people thougth they were too good for it. the simple fact is Changing an Incontinent patient while on dialysis puts the patient at risk for more harm than it does good.

Trauma Columnist · Aug 28, 2009

Yes, withdrawal is an option: dialysis is to sustain a decent quality of life. And yes, I've had pts withdraw for the very reason that they can't stand the four hours of dialysis without soiling themselves.

Dialysis units are big open rooms - there is no privacy, the hoyer doesn't fit into any of the bathrooms in any unit I go to (and I've been to 11), there are no stretchers, the needles are just that: metal canulas of large gauge and they get pulled out very easily leading to death in 3-4 minutes by exsanguination so flipping them isn't always an option.

Lacie, BSN, RN · Aug 28, 2009

Most units are not supplied with washcloths, towels, or other personal items that may be required. I know in the units I have worked with only 1 RN and 2 PCT's on hand and a 90kg pt there is no way 2-3 of us can be tied up in the patient bathroom trying to clean up or manuver a patient safely. Open bay gives no privacy. I have been very much known that if a patient arrives in this condition then I dont give treatment and will call the NH to send staff and materials to take care of the situation or I am unable to provide treatment. Also you would be surprised how many NH nurses will give meds like MOM, etc before coming to dialysis!!! Outpatient dialysis patients are ideally supposed to be ambulatory or able to perform self care. But I have patients who are literally in fetal positions from NH and have no sense of where they are recieving outpatient treatment which is well beyond what outpatient clinics should be providing. Or the very confused pt who attempts pull out thier cvc or get out of the chair every 2 seconds. We are not permitted to use soft restraints in this setting nor have the staff to provide the one on one care some of these pts require when on dialysis. These type pts should be in an acute dialysis setting but more and more of higher acuity levels are being sent to chronic settings. Before being judgemental go work in those shoes for a few years.

traveler RN · Aug 28, 2009

This is for the er person who feels you can get 2-3 people together to clean an incontinent pt. First of all we work in one large room wth recliners and no stretchers and no curtains. We do not have laundry services which also means there are no laundry hampers. People who are already angry because they have to be on the machine and one pt who is incontinent upsets an entire room. Some will make loud vocal and vulgar comments. The situation is made worse due lack of a supply room and diapers to change them. O/p clinics are just like waiting rooms . You would not go to your MD or dentist and expect the staff to change you if you were incontinent. You are sent back! PCT's do not and will not change the pt's as every clinic's policy addresses this issue. When I first started in HD, I felt like you did. Clinic adm. clearly stated their policy. We do not have the staff and we are not in-patient. We do not take staff away from the tx area to clean pts.

**canoehead, BSN, RN** · Aug 31, 2009

I understand you don't have the equipment and privacy, but I'm saying you should be provided with them. If someone is having a treatment for 4-6 hours a day it makes sense that they may need to use the restroom- this is a management oversight and they should get you the staff/equipment! It's not like an hour long doctor's appt, we're talking multiple hours, and even at the doc's they have bathroom facilities!

I read that disconnecting someone from dialysis makes the treatment less effective, and totally get that. Using large bore access, and not being able to move people is really a moot point, because people with central lines and art lines poop and pee too, and we deal with that.

If someone soils themselves in the WR of the ER we give them privacy and facilities to clean up, and assist them if they can't help themselves.

Perhaps I'm saying that there should be a higher level of care available to those who need stretchers, and personal care during their treatments. Not just the LaZBoys and inpatient, and that's it, but some sort of middle ground. What do you think? Are you all thinking that if kidneys have failed then once they can't physically tolerate outpatient dialysis they should go to hospice?

SuesquatchRN, BSN, RN · Aug 31, 2009

I worked in a NH that accepted dialysis patients and with two exceptions, who were continent of bladder and bowel, the rest of the patients should have been allowed to die. They were being kept alive because the wives couldn't let go. Guilt, denial - just oculdn't let go. Their husbands had long since ceased being aware of anything, let alone their surroundings.

Yes, more people should be encouraged to have care withdrawn.

traveler RN · Aug 31, 2009

You still don't get it. Medicare pays only so much for tx and a lot of the other cost the clinics do not get reimbursed for. There are clinics in this country where the pts. must bring their own supplies. At the end of each month each and every supply is counted and if the usage is getting above their projected budget, they start looking at methods to reduce the cost and supply. A lot of clinics have a strict no overtime policy, so the tx's have to be able to be conducted with a 15-20 min turnover so the next tx can get started. So saying that we should be provided with incontinent supplies is a moot point. Just having a day where no tech has called off is a good day. I have spent many a day being tech/nurse when shortstaffed, sometimes there may only be myself and 1 other person to get needles in and pts. on the machine for sometimes 14-20 people until someone can be convinced to give up their off day and come in to help. So you think I have time for an incontinent pt, not on your life. Meds must still be passed, cath. pts may need to have Cath-Flo for poor bloodflow and frquent machine stopping while keeping in mind that I may still have 1-2 pts waiting for the chair. As I said before you are in-patient and in order to be cost effective and attract people to work in the clinics, this is not going to happen. The pts do come off the machines to use the BR, but they must be able provide self care. It would be good for you work in the clinics to really see what's it like and not just read about it, I have worked ER!

Trauma Columnist · Aug 31, 2009

My background is level one trauma center and I work as an APN in both dialysis clinics as well as an ER so I really do feel that I can speak to this subject - outpt dialysis is just that: outpatient. The pts are to be self-sufficient and/or have a family member come with them to take care of extra issues. There is no way to even get a hoyer lift into a bathroom let alone that a hoyer lift is not a transport device, but rather a transfer device.

And yes, when a pts quality of life is so low that they are no longer continent and can not take care of their basic hygiene needs and are oblivious to the world around them, then withdrawal is a humane option.

I always, always have the end of life talk with my patients when they begin dialysis because most people look around the unit and say "oh I would never want to be like", "they don't have any quality of life", etc..

Dialysis is not to save a life but rather to enhance it and keep a positive quality of life. Our patients should not just "exist" but rather "live."

Lacie, BSN, RN · Aug 31, 2009

I've worked ER, Trauma, Burn ICU and Open Heart long before I entered working in dialysis. Yes we also had staff, supplies and those cost went in with the housekeeping. Dialysis outpatient clinics dont have housekeeping much less laundry services. Think of a conveyor belt - pretty much that is what outpt dialysis is. Shame but a fact. To have 1-2 people leave my floor to tend to one incontinent patient would leave only one staff member to tend to every pt on the floor and remember we dont have code buttons at our chairs or emergency bells. Most dialysis clinics are "for profit" yet depend on it's major payor of medicare/medicaid.I went into it thinking "yep I can change things" guess what No way lol. Example I was the DON yet worked the floor every day as we didnt have any other RN's to work in our area. Dialysis is very specialized to start with and most nurses would rather work hospital where there are better benefits, hours, and treatment. It is a very different world then hospital nursing by a long shot. I suggest go try working in it for awhile just to get a taste.