CVVHD - in over my head!!

  1. I've read some of the CVVHD posts and apologize if I'm asking questions already answered but there were too many posts to sift through for the situation I'm in:

    I've been an ICU nurse for just over a year so keep this in mind please.
    I've taken care of maybe 3 CVVHD patients in my time. I work nights and there is always a dialysis nurse and nephrologist on call to troubleshoot if needed.
    Each time I took a CVVHD patient I was coaxed into taking the assignment because there was always a nurse on the unit to troubleshoot it who was familiar with CVVHD, so I didn't worry too much because if the machine gave me trouble, I just called over to one of them and they were fine with that.
    I got very basic instructions in how to return blood back to the patient in emergent situations, empty and change bags when needed and troubleshoot the "balance" alarms and that was about the extent of my CVVHD skill and knowledge.

    Last night I took another CVVHD patient only to find out that I was the most knowledgeable person about CVVHD on the unit, no one else working that night even knew as little as I knew about managing a CVVHD patient.
    I know that I could call dialysis if needed but wouldn't the line clot off or something worse by the time I got a response from them?

    The patient was unstable on vasopressors and that seemed to be my biggest trouble, the CVVHD ran itself just fine as long as I kept up with the bags.
    I fear that I'm in over my head and that there is a lot to know about CVVHD that I don't know and wonder if I have any business at all taking care of these patients.

    I'd welcome a dialysis nurse's perspective even though they might be freaked out that someone with my limited knowledge has been taking CVVHD patients but also any other ICU nurses who take care of these patients.
    How much do I need to know to take on the care of a CVVHD patient? If not enough already, should I be refusing the assignment?
    Last edit by RN34TX on Feb 8, '05
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    About RN34TX

    Joined: May '04; Posts: 1,427; Likes: 374
    RN; from US
    Specialty: 17 year(s) of experience

    11 Comments

  3. by   11:11
    I dont have much more experience with CVVHD than you but I might be able to offer a couple of things.

    As far as clotting off that is not the end all of all things. When a pt clots off I just take them off then call dialysis to bring up a new set and put the pt back on. I'll let the nephrologist know but half the time they seem to wonder why I'm calling them. We dont do the setup where I currently work.

    Remember to flush your catheter per protocol after taking them off. If you switched lumens before taking them off you might have to stay with that lumen.

    If the pt is getting too unstable I might lower my goal for what I take off each hour or just stop taking of period. Then if they stabilize I start taking off again. If the pt cant tolerate removal theres mothng you can do to make them.

    As far as having any "business" taking these pts, have you had a CRRT class and are you certified in your facility? Both hospitals Ive worked in you have to take the class before any pts. In my present job there are a few ppl who took pts without the class but with a charge or neighbor who was experienced. Not that I agree with that but...

    Ive taken CRRT classes three times for a total of 16 hours before even getting a pt. I still felt like I was over my head and still do.

    I think CRRT is one of those skills that you have to do to get comfortable with. We can get familiarized in class but the knowledge and feel comes from doing.

    Personally I think you are ok and should feel the way you do, it'll keep you on your toes-

    11
  4. by   sockov
    Quote from RN34TX
    I've read some of the CVVHD posts and apologize if I'm asking questions already answered but there were too many posts to sift through for the situation I'm in:

    I've been an ICU nurse for just over a year so keep this in mind please.
    I've taken care of maybe 3 CVVHD patients in my time. I work nights and there is always a dialysis nurse and nephrologist on call to troubleshoot if needed.
    Each time I took a CVVHD patient I was coaxed into taking the assignment because there was always a nurse on the unit to troubleshoot it who was familiar with CVVHD, so I didn't worry too much because if the machine gave me trouble, I just called over to one of them and they were fine with that.
    I got very basic instructions in how to return blood back to the patient in emergent situations, empty and change bags when needed and troubleshoot the "balance" alarms and that was about the extent of my CVVHD skill and knowledge.

    Last night I took another CVVHD patient only to find out that I was the most knowledgeable person about CVVHD on the unit, no one else working that night even knew as little as I knew about managing a CVVHD patient.
    I know that I could call dialysis if needed but wouldn't the line clot off or something worse by the time I got a response from them?

    The patient was unstable on vasopressors and that seemed to be my biggest trouble, the CVVHD ran itself just fine as long as I kept up with the bags.
    I fear that I'm in over my head and that there is a lot to know about CVVHD that I don't know and wonder if I have any business at all taking care of these patients.

    I'd welcome a dialysis nurse's perspective even though they might be freaked out that someone with my limited knowledge has been taking CVVHD patients but also any other ICU nurses who take care of these patients.
    How much do I need to know to take on the care of a CVVHD patient? If not enough already, should I be refusing the assignment?
    are you using the Primsa CVVH machines? If so, then it really walks you through each problem. If you have a pt. on vasopressors, then try to minimize the fluid removal. You can always turn it off and still have the pt. dialyse.
    also, if you run into a problem. Just return the blood. If you don't feel safe doing that. Just stop the machine then. Disconnet the pt. from it and hook the lines up to a flush. Notify the nephrologist as well.
    Also, sometimes we turn the machines off due to short staffing, and they are usually grouped with another pt. Sometimes there are nights where you just can't manage the machine safely, so we decide to turn it off and re start the next day when staffing is better.
    sorry to say, that is how it is these days with the shortage of critical care nurses.
    Just keep the pt. safe and all is well.
  5. by   KimberRN1
    I work in MICU and we do tons of CRRT....we basically had a 4hr class then off to the races...lol...Luckily we do so much there seems to be someone on the unit who can help out if needed because everyone has a good deal of experience in it......When we have a CRRT we are "suppose" to have one pt but it's not always the case, but it should be.......I actually really like doing CRRT, it's great as long as it's running good...but when the damn thing keeps ringing off it's a major pain in the rear!!!
  6. by   suzanne4
    Quote from RN34TX
    I've read some of the CVVHD posts and apologize if I'm asking questions already answered but there were too many posts to sift through for the situation I'm in:

    I've been an ICU nurse for just over a year so keep this in mind please.
    I've taken care of maybe 3 CVVHD patients in my time. I work nights and there is always a dialysis nurse and nephrologist on call to troubleshoot if needed.
    Each time I took a CVVHD patient I was coaxed into taking the assignment because there was always a nurse on the unit to troubleshoot it who was familiar with CVVHD, so I didn't worry too much because if the machine gave me trouble, I just called over to one of them and they were fine with that.
    I got very basic instructions in how to return blood back to the patient in emergent situations, empty and change bags when needed and troubleshoot the "balance" alarms and that was about the extent of my CVVHD skill and knowledge.

    Last night I took another CVVHD patient only to find out that I was the most knowledgeable person about CVVHD on the unit, no one else working that night even knew as little as I knew about managing a CVVHD patient.
    I know that I could call dialysis if needed but wouldn't the line clot off or something worse by the time I got a response from them?

    The patient was unstable on vasopressors and that seemed to be my biggest trouble, the CVVHD ran itself just fine as long as I kept up with the bags.
    I fear that I'm in over my head and that there is a lot to know about CVVHD that I don't know and wonder if I have any business at all taking care of these patients.

    I'd welcome a dialysis nurse's perspective even though they might be freaked out that someone with my limited knowledge has been taking CVVHD patients but also any other ICU nurses who take care of these patients.
    How much do I need to know to take on the care of a CVVHD patient? If not enough already, should I be refusing the assignment?
    Unfortunately you are setting yourself up for trouble. When you are assigned that patient, they are fully your responsibility, even if there is someone there for you to ask questions of, etc. If a lawsuit would come from something, the patient is considered yours, you just delegated a part of the care to the other nurse. Same goes for med-surg nurses that float to an ICU and are told that a regular staff nurse there will read their strips etc for them....they are still responsible 100% for that patient and for accepting the assignment.
    What if that other nurse is tied up with their own patient, etc?????

    You are setting yourself up for trouble. Did you actually get a legitimate course in caring for this type of patient, as well as a preceptor for a few runs or were you thrown to the wolves?
    Last edit by suzanne4 on Jul 18, '05
  7. by   darienblythe79
    I completely agree with Suzanne. I work at a facility that only allows RNs that have been to an 8 hour class as well as have at least two full shifts of preceptoring with an experienced nurse before we can take the pt- no exceptions. You are taking a huge risk on your license by accepting the assignment without using Safe Harbor. That is something that any nurse in Texas is free to use as you feel that you are in a situation to take an assignment that you are not comfortable with. It will not protect your job if a suit occurs, but it will protect your license. Check out the board of nursing's website for more info. Good luck.
  8. by   RN34TX
    Thank you all for your input on this old thread I posted nearly 6 months ago.
    I have since become more comfortable with CVVHD patients after gaining more experience but definitely agree that it was an inappropriate way to learn.
    I found the mixed reviews of my situation interesting in that some of you felt that a formal class with preceptorship was an absolute must while others felt that OTJ training was not only appropriate, but the only realistic option in today's healthcare environment.
  9. by   Geeg
    I agree with Suzanne, you could get into some big trouble. Everything is fine until the machine starts screaming, and those prisma screens start a flashing, things can go awry quickly, especially if your pt is very dependent on the therapy to prevent acidosis.
  10. by   suzanne4
    Today's health care environment makes you want to have the more formal program than ever before. G-d forbid that something happens and case goes to court, how do you explain that this is the way that ......RN showed me how to do it. Then they will ask for your training, what type did you have, how many hours with a preceptor, etc. If the answer is none, you get hung out to dry and could lose your license that you worked so hard to get.
  11. by   RN34TX
    Quote from suzanne4
    Today's health care environment makes you want to have the more formal program than ever before. G-d forbid that something happens and case goes to court, how do you explain that this is the way that ......RN showed me how to do it. Then they will ask for your training, what type did you have, how many hours with a preceptor, etc. If the answer is none, you get hung out to dry and could lose your license that you worked so hard to get.
    Agreed. I should have been more insistant on getting better training (or any at all for that matter) prior to taking those assignments.
    I guess I was fine with it because I always had another nurse working with me who was comfortable with it, but then one night I was the only nurse who knew anything about it and that's when I really felt in over my head.
    Thanks for all of the input.
  12. by   suzanne4
    Problem that arises with this is that even if there is someone there as a back-up, the patient is still listed as being yours. It doesn't state 1 1/2 nurses on the assignment sheet, so you shoulder the blame. Same thing happens when a med-surg nurse gets floated to ICU and has no experience. They are told that someone will read their strips for them, in the eyes of the BON, that is just something that is being delegated by the med-surg nurse. The nurse is ultimately responsible for whatever happens with that patient, not the person who is reading the strips.
  13. by   proteinC
    Quote from RN34TX
    I've read some of the CVVHD posts and apologize if I'm asking questions already answered but there were too many posts to sift through for the situation I'm in:

    I've been an ICU nurse for just over a year so keep this in mind please.
    I've taken care of maybe 3 CVVHD patients in my time. I work nights and there is always a dialysis nurse and nephrologist on call to troubleshoot if needed.
    Each time I took a CVVHD patient I was coaxed into taking the assignment because there was always a nurse on the unit to troubleshoot it who was familiar with CVVHD, so I didn't worry too much because if the machine gave me trouble, I just called over to one of them and they were fine with that.
    I got very basic instructions in how to return blood back to the patient in emergent situations, empty and change bags when needed and troubleshoot the "balance" alarms and that was about the extent of my CVVHD skill and knowledge.

    Last night I took another CVVHD patient only to find out that I was the most knowledgeable person about CVVHD on the unit, no one else working that night even knew as little as I knew about managing a CVVHD patient.
    I know that I could call dialysis if needed but wouldn't the line clot off or something worse by the time I got a response from them?

    The patient was unstable on vasopressors and that seemed to be my biggest trouble, the CVVHD ran itself just fine as long as I kept up with the bags.
    I fear that I'm in over my head and that there is a lot to know about CVVHD that I don't know and wonder if I have any business at all taking care of these patients.

    I'd welcome a dialysis nurse's perspective even though they might be freaked out that someone with my limited knowledge has been taking CVVHD patients but also any other ICU nurses who take care of these patients.
    How much do I need to know to take on the care of a CVVHD patient? If not enough already, should I be refusing the assignment?

    hello im a new member of this interesting web site for nurses. in view of youre problem about CVVHD is more focus on trouble shooting of the machine and what to do if the patient become unstable .. first is to consider to slow down the blood flow if blood pressure becomes compromised because the machine pumps around 5 liters of blood in and out of the machine that may affect patients cardio vascular status. other consideration is to ask the docs to start some inotropes to tighten vascular vessels and increased blood pressure.. to trouble shoot the machines liked prisma...the company that supplies this provides information on how to trouble shoot if the machines alarms RE: high pressure on return...they provide step by step measures on how to trouble shoot those incidents the nephrologist or the dialysis nurse should have those trouble shooting guides and u can ask them to have one in each machine in case no one knows how to fix it a helpful guide is always available...training on these machines and other machines is vital, it should be a protocol in every unit to provide such training on these machines ...which sometimes the manufacturer provided the training....HOPE I HELP....

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