newbie, need input

Six months in and you will be the only RN???

The good news: you have expressed your concerns in such a way that are a.) relevant to the issues at hand, and b.) shows that you are a critical thinker. You will need those skills to survive, not to mention keep your patients safe.

The bad news: If you are indeed on your own as the principal decision maker after only six months, then much of these decisions (like putting the patient on the machine instead of sending them to the ER, or vice versa) will be learned as you go--and that takes time. It also puts you at greater risk for making a dumb decision.

Since you have a manager that is an RN, I do hope you will be working only the hours when he/she is on site?

As to your scenario examples, keep in mind you need a different kind of thinking cap when working with unstable patients coming in the door. Some of this comes with getting to know your patients and what looks "right" for them, given their habits, medical hx/diagnoses, and medications. Some patients will show up and as you say just look "off." A great percentage of the time they just need dialysis.

Think about the mechanics and physiology behind why the patient in your example "just needed dialysis." What is his/her symptoms, cardiovascular history, medication history, and how does fluid balance and uremia affect this patient's particular presentation? Think about it. Why did putting the patient on dialysis increase his/her BP? (Hint: think about PVR and cardiac preload and afterload...and don't forget about what meds they have been taking). That's right! You get to play sleuth! It's great!

This stuff is fun to learn if you have back-up. If not, it's terrifying.

Case scenario for ya: A patient shows up for treatment who is usually mobile and ambulatory, but presents today with weakness, and difficulty in weight bearing and transferring. What issues might you suspect, and where do you begin your line of questioning for the patient?

This is how you have to think --and yes, I know, it's hard to do so when you have ringing phones, multiple assessments to do, and turnover going on all at the same time. It gets to be absurd, right? :).

But much of this will become second nature in a year or two. I just hope you have back-up in house.

I work for one of the big two, and I can be on my own after 6 months.(Small clinic, so only 1 RN per day unless one of us needs to tech for some reason) I will be there when the manager is working probably 90% of the time. She probably won't keep coming in when I work at the crack of dawn but will be there the majority of the day. It just makes me nervous to learn as I go. Is there a site I can read case studies and scenarios? I think that would be really helpful. As for your scenario above, I guess first I'd have to see what other issues they have. Alert/oriented? did they fall? stroke? how long since the last tx? uremic? Am I in the neighborhood?

How many chairs does your clinic have? Correct me if I'm wrong but don't you see the same patients over and over? I would try to learn as much as I could about each patients medical condition so I would know that the guy with cardiomyopathy is going to respond differently to fluid removal than the lady with autonomic dysfunction. You can initiate a dialysis treatment in these people but you need to watch them alot closer. Of the patients you describe the one that would scare me the most would be the chest painer because renal failure accelerates cardiac disease which is the leading cause of death for all patients. Some day he may really be having an ischemic event but he will be ignored because he always complains. If you haven't already take an ACLS course so at least you know what to do when he does crash and burns.

I work for one of the big two, and I can be on my own after 6 months.(Small clinic, so only 1 RN per day unless one of us needs to tech for some reason) I will be there when the manager is working probably 90% of the time. She probably won't keep coming in when I work at the crack of dawn but will be there the majority of the day. It just makes me nervous to learn as I go. Is there a site I can read case studies and scenarios? I think that would be really helpful. As for your scenario above, I guess first I'd have to see what other issues they have. Alert/oriented? did they fall? stroke? how long since the last tx? uremic? Am I in the neighborhood?

You're in the neighborhood-- the "neighborhood" being one that makes you think. And thinking is paramount in caring for the ESRD patient.

Chisca wisely mentioned that seeing the same patients over and over gives you a great deal of insight as to what might be wrong with any patient that presents outside the norm of their usual.

In my little scenario, there are multiple reasons a patient might present with weakness. You ticked off a couple of them. This is where Chisca's mention of "knowing the patient," can come in handy--what are their usual habits when it comes to adhering to their treatment plan; what are their diagnoses; what sort of shape is their heart in; what are their dietary habits; what is their fluid status; their medications; and just how out of their norm is this presentation...? And the list goes on and on.

There's not a right or wrong answer to my scenario (although I had hyperkalemia in mind), I just want you to feel confident in stretching your wings when it comes to learning how to put pieces of the puzzle together.

As to your particular patient in your OP, your manager likely "knows the patient." That helped him or her decide that the patient was not in immediate danger of demise, and that getting the patient on the machine is what they needed.

In years past, dialysis nurses often had some sort of ER/ICU background and a firm grip on cardiovascular pathophysiology. It's not so easy these days if one does not have that background, especially since cardiovascular components are a huge contributor to mortality/morbidity in ESRD patients.

Here's a simple google-search activity that will help you with one of the most common cause of pre and inter-intradialysis issues:

1.) preload/afterload (and then think about how fluid removal affects certain dialysis patients in that context-- either positively and negatively).

2.) How does a flabby heart (heart failure) or someone with diabetic vasculopathy (or both) affect how the patient will respond to dialysis?

If you get the basics of this, it will help immeasurably in your ability to "sleuth-out" and sift one problem from another!

Keep at it! You're on your way.

If you haven't already I would recommend joining ANNA as this would give you access to their magazine Nephrology Nursing Journal. The Jan/Feb issue had articles that would directly relate to some of the questions you have. Like:

Cardiovascular risk factors in patients on dialysis

Hemodialysis induced myocardial stunning: A review

Understanding hypertension in patients on hemodialysis

Welcome to wonderland. No, I have no idea just how deep the rabbit hole goes, but congrats on jumping in with us! It's always a good idea to ask your CCHT's about your patients' histories of tolerating treatments. Sometimes the patients won't trust a "newbie" with some critical info, yet they'll openly share it with the staff they've been around for a while. -Nurse-itis- has no place in a chronic dialysis unit; the more you involve everyone, the better off you'll all be. Be brave!