incontinent NH pts

81Bubbles, BSN, RN · Aug 31, 2009

Even if the supplies and staff were there. It is dangerous! A HD patient's access is their life line! For many of these patients, if their aceess becomes infilltrated they will die. because they have exausted all of their orther usable points in thir vascular system. For the vast majority Patients are cannulated with 2 x 14g or 15g needles every tx directly into their venous system. Theses are no IV cannula they are Stainless Steel 1in or 1.5 inch large bore needles!

The comunity based dialysis centers are out-patient facilities. If the patient can not function as an out patients they either need to go back to the Hosp/rehab or have their own personal assistants who come to HD and stay during HD with them to take care of their needs that go beyond why they are there.

Diaper rash is a lot less deadly than sepsis, hemorrhage, or infiltration!

**canoehead, BSN, RN** · Aug 31, 2009

For the vast majority Patients are cannulated with 2 x 14g or 15g needles every tx directly into their venous system. Theses are no IV cannula they are Stainless Steel 1in or 1.5 inch large bore needles!

OK, the incontinence I don't like the policy, but I'm getting why it exists. I understand why you don't do clean ups, but still think the budget shouldn't be so tight that you can't. Anyway- re withdrawal of treatment- I agree totally that if the pt is oblivious LET THEM GO!! I was thinking more about some 50-60yo that are incontinent but still lead full lives.

Re the cannula- WHY are you using stainless steel?? I agree, totally inappropriate for them to move their arms at all with a frigging sword stuck under their skin, but we have 14G and 16G IV catheters available that would pose a much lesser risk of injury.

Thanks to everyone for answering my questions. I realize I've absolutely no experience with your issues, but I'm interested too. :yeah:

GeauxNursing · Aug 31, 2009

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.

The point isn't moot. It's their lifeline! It's a possible, actually likely, infiltration waiting to happen! Pain for the pt., rescheduling of tx, pain for the pt., possible visit back to the surgeon (worst-case scenario!)

I'm just saying...

Trauma Columnist · Sep 2, 2009

Canoehead - I too thought it was weird to use stainless steel needles with the catheters being so much safer. However, we are talking about high-pressure arterial lines - no way would a catheter work - it has to be stainless steel in order not to collapse.

As to mortallity in dialysis pts: 20% of dialysis pts die every year. And...they die not because their kidneys don't work but rather because they calcify their coronary arteries.

traveler RN · Sep 2, 2009

Thank you, I hope Canoehead is starting to see the light. That access is their lifeline and must be protected. Lg blood volumes are exchanged rapidly in 3-4 hrs and a small diameter cath you refer to is not feasible. They can exsanguinate in a matter of minutes on the machine and can start bleeding after tx while in the waiting room or parking lot. This is one reason why clinics have lg open rooms so we can move quickly to assist them. Self care pts. have dislodged their needles in the BR and trying to assist them is crucial and a risk to staffers. I know of 2 incidents where staff have had needle sticks trying to control the bleed. A good day in dialysis is when you have no call offs, clotted accesses, lines, dialyzers, no bleeds or drops on Bp. It means I can get a whole lunch!

81Bubbles, BSN, RN · Sep 2, 2009

TravelerRN...WOW you have a lot of requirements for a good day...LOL....I guesss I've only had a handful of good days.

traveler RN · Sep 2, 2009

I know, but one of these days. I can only dream:lol2:

**canoehead, BSN, RN** · Sep 8, 2009

Canoehead - I too thought it was weird to use stainless steel needles with the catheters being so much safer. However, we are talking about high-pressure arterial lines - no way would a catheter work - it has to be stainless steel in order not to collapse.

In the ICU art lines are the same plastic catheters we use for venous IVs...they are used for monitering and blood draws. Are your art lines different? I know they must be bigger for greater flow, we've got the same catheters in 12 and 14G.

Trauma Columnist · Sep 8, 2009

No - these stainless steel needles have to withstand the blood flow rate that the dialysis machine puts out. Its much much higher pressure than just an art line (I've worked adult ICU). The ideal blood flow rate is 500 cc/min so it is moving. When pts dislodge their needles (and this is a pretty common occurrence) the pt can exsanguinate within minutes and unfortunately I know this happens too.

km5v6r, EdD, RN · Sep 9, 2009

In the ICU art lines are the same plastic catheters we use for venous IVs...they are used for monitering and blood draws. Are your art lines different? I know they must be bigger for greater flow, we've got the same catheters in 12 and 14G.

Keep in mind that an Art line has a continuous flow of fluid INTO it from a pressure bag. A dialysis needle has to have the ability to withstand the continuous PULL of blood through the needle at a rate of 400-500 ml/min and maintain the pressure of that pull at less them 200 mm. Most plastic IV catheters with walls thin enough to not damage the vessel will collapse at that amount of suction. Pushing fluid down the catheter of an Art line or Central line will prevent the walls from collapsing. By the time the wall is strong enough to withstand the pressure it is very thick and/or very stiff. It seems it is not possible for needles to have both thin; smallest possible hole; and strong walls that don't collapse under pressure. Also, dialysis needles are not always placed going in the direction of the blood flow. The Art needles may need to be placed facing "downstream" or retrograde. The amount of pressure in the vessel would have a softer plastic catheter bending back on itself. Temporary dialysis catheter placed in the acute unit for short term dialysis are EXTREMELY stiff catheters that could go through the back wall of a vein quite easily. Heck, I had one that went through the wall of the heart and into the pericardial sac. Pericardial effusions don't dialyze well, no the pt didn't survive and yes the CXR had been read as good placement. I told the Doc when I started the treatment the blood didn't look right and the art pressure numbers were wrong. He told me he read the CXR himself and it was good placement.

But back to the orginal question about incont NH patients. Not only is the lack privacy, supplies, staff, time an issuse in cleaning a pt up but there is also the risk to the other people in the room. Dialysis chairs are very close together. Keeping stool contained within a diaper, within clothes is much better then risking bacterial infection in the catheter of the patient in the next chair that is within arms reach. Not that the next person would reach over and play in the mess; though some would; it would be very easy to accidently brush against their chair, table, supplies, or belongs and not even realize it.

It is hard to realize that the decision if someone lives or dies is based on if they can preform the simple act of personal toileting.

Kathy

springfieldrn · Sep 23, 2009

This is a terrible situation for pts and staff! It's an infection control nightmare too. Having a unit specifically for incontinent patients would be ideal but there is already a shortage of units, chairs and staff.

81Bubbles, BSN, RN · Sep 23, 2009

This is a terrible situation for pts and staff! It's an infection control nightmare too. Having a unit specifically for incontinent patients would be ideal but there is already a shortage of units, chairs and staff.

In theory that sounds super but in reality that would be crazy dangerous. Just becuase someone is incontinent doesn't mean that their not all "swapping Bugs". Besides it does not touch the danger of moving them around while hooked up with needles or their catheter open. The absolute safest thing to do is keep it contained until their treatment is over and they return to their facility they came from.

I know you people mean well. But there is no way to make changing a diaper on dialysis the better option. The risks are too great. The risks that come from changing a diaper are deadly, the risk to keeping it on are sad and uncomfortable. People die from bleeding out, unrepairalbe damage to accesses, and sepsis People do not die from diaper rash.