Please help new Dialysis RN

[mia]

Please help me. I am a new RN who is working in an outpatient chronic care dialysis facility. I have so many questions that I really need answers to.

First, how do you maintain sterility when hooking up patients with subclavian catheters?? I can do it for the dressing change but when I am hooking up without assistance it is almost impossible without changing my gloves over and over. The nurses in my facility say "I don't know why they say its a sterile procedure, it is really just clean". Is this true?? If not how do you do it??

Next... What do you do when you have a catheter that you can not aspirate the dwell from?? In my facility as long as you can push a saline flush through you go ahead and hook up and give the treatment anyway. This scares me. Is this safe?? ALso if the arterial line on the catheter won't pull they just switch the line and make the venous the pull instead. How long can you do that for (in my facility I have seen them do this till the catheter is not functional anymore)? As a new RN such practice makes me very nervous...Am I just acting like the "super novice"?

Lastly (for now) many of our patients have very prolonged bleeding times (and they bleed alot). To compensate the nurses and the techs just cut the heparin dose. I feel uncomfotable consistently doing this without the MD offically changing the dose.

Am I being overly cautious? What do you do when this happens?

Please someone advise me . I think the staff is getting irritated by my constant questions but I really want to make sure I am being safe. In nursing school we really did not cover dialysis to a large extent so I am really in the dark here. The last thing I want to do is develop bad habits.

I appreatiate any comments, advice and tips you can give me!!

Thanks so much!!!

Mia:confused:

[TELEpathicRN]

I have seen some cath's that wont aspirate and you just have to reverse the lines, you need to put a call in to the doc and tell them that the line isn't functioning properly and the pt needs to be sent to the hospital so that interventional radiology can replace or TPA the line.

About the Heparin dosage, in chronic units, unless you have a protocol, you can't just cut the heparin dose without a doctors orders!!! I just switched from a chronic to an acute unit and LOVE it!!!!!! We have a heparin protocol that tells us what to do with the outpatient hep bolus if the pt is scheduled for surgery, or in with dx of GI bleed, etc...also tells us to up the dosage if the pts are clotting the dialyzers, etc...

Sounds like you are working in a scary environment!! I wouldn't recommend that a new grad work in such a setting. you need to have strong assessment skills and be able to stand up for what you know is right!!

Does your DON or charge nurse know what is going on in your unit?????

Please post a reply, I am curious to see how you are doing

Also, A PCT does not have the athority to make adjustments to heparin bolus or push the heparin, unless it is legal in your state. Are they pushing heparin in your unit????

Hope to hear from you soon!! :confused:

[TELEpathicRN]

As for the sterility when hooking up caths, after you unscrew the end cap from the cath, dont touch it and immediately hook up the line to it, do this for both lines. It is hard at first, but you will get the hang of it. If you ever get the proper instruction, dialysis is very easy and routine (putting on and taking off) and you can spend more time assessing the pts, teaching them about their diets and meds, etc.......

[ageless]

Taking care of a dialysis catheter is similar to taking care of a central line. Use a mask and gloves. After scrubbing the luer lock connection with an antiseptic, open the catheter taking care that the lumen of the catheter does not come in contact with anything but the sterile end of the syringe, cap, or dialysis line. This is where the sterility comes in to play. Your hands will not be sterile because you are holding the outside of the catheter.

After establishing that the catheter is seated correctly, by checking the suture and the cuff, it is acceptable to use either the venous or arterial line to pull from when using a catheter because they are both venous blood accesses. (You don't have this option with a graft or fistula) Recirculation studies have proven this. If one lumen of the catheter becomes clogged, activase or something similar is instilled to dwell in that lumen for 30-45 minutes to establish patency. This may be done only in an in-patient facility in some places. Using the arterial lumen as the venous and vice versa does not shorten the "life" of a catheter.

Most dialysis centers have policies (standing orders) in place that allow dialysis nurses to titrate heparin. Check your policy and procedure manual for this.

Let me know if you have any more questions. I'd be glad to help. You can email me directly if you wish.

[Northern nephron]

I am a Canadian nurse and in our unit we believe in the "clean not sterile" train of thought. These patients are running around all over the place with their catheters and they are therfore not sterile. Once the cap/line connection is cleaned with your units cleanser of choice, remove the cap and connect to the syringe..remembering that the tips are the connectors that must be kept "clean". Practice will make this easier for you.

Regarding the switching of lines...this can be done with no reprocussion to the patient and I have seen many lines that run switched from day one.

Remember that no nurse likes working with a nurse that does not ask questions if they are unsure. Hang in there...renal nursing can be alot of fun.

[mia]

Thank you all so much for taking the time to answer my questions!

I have taken everyones advice and I feel alot more comfortable now. Even better is that I have been offered a hemodialysis position in a peditric hospital. The staff seems really supportive of new nurses and I have been promised a precetorship with a seasoned dialysis nurse. I think I will really learn ALOT working with this team!! Im so excited!! Thank you all so much for your support and advice!!

Mia

[jnette, ASN, EMT-I]

The above posts were all right on ! You will find that very few (if any?) clinics use sterile procedures for working with caths... we used to only for dressing changes, but then even that went back to "clean gloves". We have standing orders to titrate heparin doses depending on how the patient runs. As for reversing lines, it is (or SHOULD BE) done only when really necc'y. The pt.'s clearance or KT / V or URR will not be nearly as good if he/she is allowed to run this way indefinately... the pt. will not be dialyzed nearly as well...if you have "online clearance" on your machines, you will see the difference immediately. So it is not advisable to run the pt. "reversed" too often. Hopefully the pt. will be able to use his/her graft or fistula in the near future (if one has been put in... not all pts. will be able to have one, for various reasons.) At our clinic, in our state, the techs do admin. the initial heparin bolus. But all our dialysis staff (regardless of title) are put thru a 3-6 wk. course in theory and practice before going on the floor.. and then they are precepted for quite some time and "checked off". You'll find, as stated by the others, that all units, clinics, etc. differ in their procedures and protocols, and there are many companies as well as private clinics. It's interesting, to be sure. And always room for improvement ! It won't be long 'til it all starts making sense... when I first started, I thought I was learning to be a rocket scientist ! Hang tuff...and keep asking questions! Don't allow yoursekf to be intimidated.. it's all in the way you ask.." Attitude is EVERYTHING !"