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madwife2002, BSN, RN 118,040 Views

Joined: Jan 17, '05; Posts: 10,271 (21% Liked) ; Likes: 6,112
Director of Nursing Services; from US
Specialty: 26 year(s) of experience in RN, BSN, CHDN

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  • Jun 16

    When I came into nursing, which was a long time ago now, I was part of the old cliché, which was to help people, I know a shocking concept in the ever changing world of healthcare.

    Never in my wildest dreams did I envision my self at the top of the ladder and that I became 'they'

    I am sure you have all heard it said 'they' want us to do it, it came down from above and 'they' need us to behave in this way. Why are 'they' giving us more and more to do? With less time to do it.

    So my question who is 'they'? In my company they are a variety of people all with the best intentions in the world. I work in dialysis and dialysis is one of the most heavily moderated specialties in this country. So lots of rules, regulations govern us and higher standards of care are expected from the dialysis community, what does this means to the direct care staff? Lots of new policies and procedures have to be initiated plus evaluated constantly.

    A definition of they-'They' are old, young, clinical, non-clinical, very experienced nurses and nurses with no floor experience, they can be male or female, any race, culture or religion. 'They' can be you if you want to be 'they'.

    'They' do have the best interest of the patients and staff when planning and implementing changes, new policies, new tools to assist changes and they are part of the company you have chosen to work at. This means they are you!! Confused yet?

    I was one of those nurses who wondered who they were and how did they know what it was like to work on a floor, how tiring it is, how hard we worked, no breaks and how do they know how it is to care for a sick or dying patients and their relatives? I spent over 15 years giving direct care to patients, I have the knowledge and experience to represent nurses-I wanted to be part of the team of 'they' as a RN.

    I worked hard to be a 'they' I took courses, I volunteer for projects, I was flexible and open to change-I love to be innovated to be part of new projects and pilots to see if it will improve the quality of care delivered to the patients. I love to audit to see how care is given, to educate where I see the need, and I am the advocate for Nurses, PCT's and other direct care staff in dialysis units.

    Do I make a difference? I know I fight daily with a team of RN's to stand up for nurses and pcts. I love the concepts of some of the ideas but I also know the reality for many direct patient care staff. I am skeptical and always open to be proven wrong to some ideas and really enthusiastic for many other ideas.

    I remember back in the day when changes would be implemented thinking to myself 'if it is not broken why mend it' of course today we have to have research to prove that something works, pilots with hundreds of steps carefully written for staff to follow.
    Why? Because we have to make sure that we do not harm a patient or a member of staff, we can only guarantee anything if we follow the steps laid out-and be prepared to change quickly if something is identified during the pilot that has the potential to harm.

    I love what I do, but I cant look back I am so far removed from the floor that I am dizzy. I often wondered how it happened and if I am as happy as I was when I was a RN working the floor in a busy bustling hospital.

    My answer to this question is no I am not as happy as I was when I was a RN on the floor, nothing in the world can compare to looking after patients, working with a team of nurses and laughing/crying so hard with patients, staff and family members. Feeling proud when I helped to support patients and families through good and bad news.

    However I do believe that I am up there, supporting the nurses by making sure I never forget my grass roots. I am 'They' and 'They' are us, whether we like it or not!!

  • Jun 16

    Death came to visit Friday, it was not kind, and it was not peaceful for my friend's mom-it was hard, she struggled so much, her mind was ready, but her body fought her to the bitter end; causing trauma to her loved ones who stayed by her side so she did not die alone. The family had discussed end of life choices, and treatment was stopped on Tuesday, with the only intervention being pain medication.

    Death is still a taboo subject that many of us prefer not to discuss. Why is this? Unless you work as a healthcare professional, the clergy and funeral directors, many people are not able to talk about it freely.

    As a nurse who has been with many patients as the end of their life, I know you cannot prepare their loved ones for the final end. You cannot say that it will be peaceful, you cannot give a timeline and you cannot promise how it will be because you really don't know. There are relatives who have no clue about what their loved one wanted. There is often no discussion about end of live choices.

    I have been fortunate to be with my sister and my mom when they breathed their last breath and it was peaceful, calm and a relief that their struggle was over. I have been with patients who have passed away peacefully without pain, without struggle and without suffering. I have also been with patients who have fought to the bitter end, every last breath being a struggle for them. It was like something from a horror movie only it was real life.

    My question is why? Why do some people have horrible deaths and some people go quietly. It certainly doesn't pertain to how they lived their life; I can vouch for that with my own eyes, experience and knowledge. My mother was a feisty firecracker of a woman who fought for everything in life, never gave in to anybody and would never hold her tongue. Yet her death was one of the most calm, peaceful I have ever experienced.

    When somebody passes what determines if it is peaceful? What would determine if death is going to be horrible? Is planning important, should patients and relatives make known what they want near the end of life? You still cannot guarantee that death will be peaceful, however everybody involved knows what their loved ones want.

    Is it the environment they pass in? Can we choose where to die?

    Hospice is a wonderful environment, where the nurses, aides and doctors are amazing. I have never seen such caring individuals. When my mom passed many years ago they were amazing, I will never ever forget the kindness my mom received and how supportive they were to my husband and myself. The atmosphere was incredible in a hospice where everything is available for support. Nothing was too much trouble; nobody seemed rushed or didn't have the time to spend with her.

    Hospital can be a frightening place for many people, yet many will die in the hospital this year. Some expected deaths and some unexpected deaths. Relatives can add peace or trauma when their loved one is dying. The circumstances of impending death play a huge role for end of life decisions.

    Is the hospital environment a good one for a peaceful death? Yes it can be. It can also be a very traumatic experience. How many things can contribute to peaceful versus traumatic-who or what determines the definition?

    Hands up! How many of us nurses have witnessed needless interventions, pain and suffering? How many of us have experienced relatives prolonging life as long as they possibly can? Does this add to the trauma of their dying?

    End of life discussions can be very difficult; but it shouldn't be; as it is something we are all going to experience as our only guarantee in life. Many people do not have a living will. Many people do not even understand the terminology 'Living Will'. It makes no sense to them, although we as healthcare professionals are much better at promoting living wills.

    Even with a living will there can be struggles to make sure your wishes are followed, but without one relatives can fight and disagree with each other about what they want. Clear precise instructions can at least highlight your choices helping relatives to make better decisions on your behalf.

    In 2007 only 41% of the population in the United States had a living will.

    In 2009 President Obama made it more popular by publically talking about his living will, saying it is a sensible choice.

    In 2013 only 1 in 3 people had a living will, 32%, Findlaw.com

    In March 2016 "American College of Emergency Physicians' stated that two thirds of Americans don't have a living will!

    The sad fact is that even with an advance directive, your designated decision-maker may still face a fight in trying to follow your instructions. It's not uncommon for doctors to disagree with a family about what should be done; it's not uncommon for family members to disagree - sharply and painfully - with one another. But, as Mr. Kottkamp said, "It's an uglier fight if you don't have the documents."

    Question of the day-Do you have a living will?

    Or are you part of the 2/3rd's that don't have one

    Less Than One in Three Americans Have a Living Will, Says New FindLaw.com Survey

    http://newsroom.acep.org/2016-03-21-...ving-Wills-Do-

    The living will needs resuscitation

    For young and old, it's wise to have a living will to state health-care wishes - The Washington Post

  • Jun 5

    There needs to be some sort of discussion going on between you and your manager. This is a form of bullying and cannot be allowed to continue. The potential for causing patients harm could be occurring here, if they do not do the vital signs and sign them off.

    Your FA ot HR needs to stop this behavior now

  • May 29

    Most places just want to educate when med errors are made.

  • May 28

    Most places just want to educate when med errors are made.

  • Mar 5

    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"

  • Mar 1

    This is a fantastic story, the ending however was so sad

  • Dec 13 '17

    So If I dont smoke, dont drink, dont do drugs and get a flu shot will I get my insurance free?

  • Dec 9 '17

    So If I dont smoke, dont drink, dont do drugs and get a flu shot will I get my insurance free?

  • Nov 23 '17

    I remember Black and White TV

    I remember when we were the only house on the road who had a telephone-calling another country was not easy and you had to book a call

    I remember we had a day off school when the first man walked on the moon!

    I remember riding my bike all the time and playing out all summer

    I remember when air travel was a luxury

    I remember being slapped and told it was for my own good

    Time out was in my room with nothing including no food!

    My favorite TV shows included the A team, Starsky and Hutch, Kojak,

    I remember my mother crossing the road so she didn't have to speak to a neighbor who had cancer! I remember feeling disappointed in her and vowed never to avoid a sick person

    I remember being frightened of the police but knew I could go to them in an emergency

    I remember being frightened of the Soviet Union and thinking the world was going to come to an end any moment

    I remember growing up in the UK and there were lots of bombings-we were taught to report suspicious packages

    I remember 9/11 when the world seemed to stop turning

    I remember laughing a lot!

    I remember horrible toilet paper, nasty cold remedies, splinters

    I could go on and on

  • Nov 14 '17

    Commuter, this is a great article and has provoked a great debate, thank you!

    When I started nursing back in the late 80's all nurses were young, most of us started at 18 and became an RN at 21-22 years old it was the norm. I was a little older at 26 but still young.

    You didn't see many older nurses back then so everybody got looked after by the young and glamorous

    Nobody ate us, the difference between today and yesteryear is the way new nurses have been trained period. Less hands on half their life in college a couple of days here and there in clinical.

    We spent 8 weeks every 10 weeks working on the floor side by side the nurses, learning hands on care.

    I remember talking to an RN who said she had been an RN for 12 years it shocked me LOL I thought gosh I can barely get through the training let alone think I will be in the job 12 years.

    So here I am one of those 50 plus year old nurses, who believe it or not has really good computer skills and keep myself abreast of all current situations. 24 years as a nurse! Loved nearly every min of it.

    I love the young nurses, I do believe there is room for them however I do believe like life there has to be a great mix of ages and experience.

  • Nov 8 '17

    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

  • Aug 30 '17

    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

  • Aug 26 '17

    I do feel for you, but the mistakes you have made could have potentially serious consequences. Have you asked this other nurse for help? Have you identified that you have problem with medication administration.
    I can understand the nurse you are working with having concerns especailly as recently i worked with somebody who made similar mistakes and in the UK she is not only practicing on her own registration but on the charge nurses registration, if that nurse knows of the problems and does not report it, then they made loose their right to practice. There is a person who trusts and relys on us to look after them and they tend to be very vunerable. I suggest when you are giving out meds you take your time and double check and ask for no interuptions.
    How we solved this problem was by the use of supervised practice which meant she had to do meds with another trained nurse until it was deemed she was ready to go it alone.
    We also implemented that the nurse who was giving out medication does not get called to phone or interupted for anything other than an emergency.

    Remember it is easy to make a mistake we are human

  • Jul 30 '17

    My hospital and my previous hospital didn't allow usage of IV phenergan anymore. It is banned here


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