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km5v6r EdD, RN

Acute Dialysis
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km5v6r has 25 years experience as a EdD, RN and specializes in Acute Dialysis.

km5v6r's Latest Activity

  1. km5v6r

    incontinent NH pts

    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
  2. km5v6r

    Scheduled induction???

    Would your daughter allow you to go to an appointment with her to discuss the risks/benefits of this induction? My daughter and son-in-law live over 4 hours away and I still work full time. I may see if one of her appointments can be scheduled on my day off and I will make the trip. Her husband is not supposed to be deployed overseas for at least another 18 months. If a trip to Iraq is in the plans we haven't heard about it yet. I think my SIL is just anxious. He was very worried last month because they didn't have a crib yet. "What if the baby comes early?" I kept try to tell him "If it comes that early it will stay in the NICU until close to the due date and you can get a crib.":nuke: Her first US was done 2nd trimester. There is another US scheduled for next week. Again I am asking why and my daughter doesn't know. UGH. Of course as a PICU nurse I see the bad outcomes and long term problems. I keep reminding myself that not all babies are born with gastrochesis, microvillas, megacolon, ect. If just feels that way from work. Thanks for the replys.
  3. km5v6r

    "Funny Codes"?

    Then when one of them asked her to check for a radial pulse, she blanked out and said, "what's a pulse?". Poor thing, she made it through school fine though:chuckle . I worked with a nurse once who was also a minister's wife. Very nice person, rarely flustered and NEVER known to say a swear word. One day one of her pt's went into VFib. Code was called, crash cart arrived and she grabbed the paddles (before hands off defib with patches were available). The paddles were labled with sternum and apex to help remind the user of proper placement. She took one look at the paddles in her hands and shouted loudly "What the H%&& is an APEX?" Pt did survive but the nurse thought she was going to die of embarrassment afterward.
  4. km5v6r

    Scheduled induction???

    My daughter is expecting her first child next month. EDC is March 25 or there abouts. Dates aren't terribly accurate because she was switching between the pill and Depo Provera for birth control. She called yesterday and said the military docs are "pushing" her to be induced. Her husband thinks an induction sounds good so he can plan his leave and make sure he is off when the baby comes. Many of her friends have also been induced for a variety of reasons lately. The way her friends were induced was to be admitted on Sunday for cervical ripening, then Pit on Monday. My daughter tends to be very passive and not ask many questions. Needless to say I have a few dozen questions and no answers. Is it common for docs and midwives to plan induction now? Is there a medical reason? Could they tell a medical reason to induce this far in advance? My concern is that dates are off and they will try to induce a baby that isn't quite ready to be born. Is this a legitimate concern? Can a EDC be accuratly determined by US now? My OB rotation was almost 25 yrs ago and I adopted my daughter when she was 6 yrs old. This area is totally forgien to me. Thanks.
  5. km5v6r

    "Funny Codes"?

    I was working in CCU and it was our turn to have the code pager. We had just finished report when it went off for the PCU and I took off. Arrived in PCU to find both shifts still giving report asking "Where's the code?" They knew the call was for their unit but not which room had called the code and since all the staff were at the desk didn't know who called the code. We all arrived at the room to find the pt standing at the bedside screaming "I'm DEAD. You have to do something. See I'm DEAD. Help me!" The man in his 30's had been napping. When he woke to use the bathroom he pulled off a telemetry lead. When he looked at the bedside monitor he saw a flat line, knew from TV that meant he was dead so he called his own code. I backed out of the room trying very hard not to laugh while the pt became more irrate that we weren't doing anything about him being dead. Others were muttering "well if he really wants us to we could go ahead and treat him".
  6. km5v6r

    dumping the prime

    All the companies I have worked for required "peeing" the lines before hooking up the pt. Even those with a dry pack dialyzer. "Peeing" the line consisted of dumping about 500 ml of saline through the lines immediately before hooking the pt up. We were told this was to remove any residual chemicals in the line and dialyzer that may have come out during recirc. The national companies tried to make policy the same for inpt and outpt. So inpt we used a dry pack, set up at the bedside and were ready to immediately initiate the treatment but still had to do a 15 min recirc and then pee the lines of 500 ml of saline. The companies then wondered why we couldn't set ourselves up, tear ourselves down, move all the equipment from one bedside to another and do 2 four hour treatments without going over the 10 hour shift. The real fun came in when you had to drive across town to another hospital. I had one out of town manager tell me his nurses were able to return the blood on one pt, drive across town, set up and have blood through the dialyzer on their second pt all within one hour. I told him then his nurses were cutting corners and were unsafe. Needless to say I wasn't terrible popular.
  7. km5v6r

    dumping the prime

    In the acute unit we would dump the prime on someone in massive pul edema that we were dialyzing to keep off the vent. If the pt was frothing that extra 250 ml of fluid could be to much. We would also sometimes dump the prime if we were resetting up a system after someone clotted and their B/P was stable. This was a decision made only on a case by case basis after a thorogh assesment. I don't know that the outpt units ever dumped the prime.
  8. km5v6r

    Clots Clots And More Clots!!!!!!

    In the acute setting with pt's who have developed Heparin induced thrombocytopenia we could not use Heparin. We would plan on rinsing the system with at least 100 ml of NS every 30 mins and planned a new set up at the midpoint of the the treatment. It means alot of fluid to add into the amount to be UFed off but it might save the system. The other thing you might talk to the Docs about the possibility of using Citrate instead as an anticoagulant. This carries it own set of risk factors. Heparin free runs can be very challenging.
  9. km5v6r

    Rough Night in NICU

    :icon_hug: After 15 yrs working with adults and in adult ICU I now work in PICU. It is different to lose a little one. Even though you know in your head that withdrawal is the best choice your heart still fights the idea. With an adult the end may be painful for the family and seeing that pain can be hard for the nurse but there can also be a sense of completion. A sense that the circle somehow has been closed and the life completed. With a little one you are dealing with not only the loss and pain of the family but also the sense of betrayal and loss of the future or potential of that little one. The heart believes that all little ones are supposed to be born health, and grow up happy. Reality is that not all do. On some level there is also the realization/fear that this could happen to me. That adds another layer to the grief/emotions of the moment. You did the right things in staying with the assignment and supporting the parents through their personal hell. It may sound strange, but go back to the NICU. Talk with the staff. They know the story and are probably reeling as much as you. They are someone to talk with who you don't have to relive every detail with. They may also have special supports services in place for these types of incidents. I am not meaning to stir up trouble but I am suprised at your being given such an assignment as a float. This is the type of assignment that only the experienced staff in my unit would take. I am not meaning to imply you don't posses the necessary skills but the emotional toll for both you and the family was excessive. You have never been in the situation of a baby leaving. It is very different and an emotional burden you were not prepared for. When you accpet a position in NICU or PICU you KNOW you will lose little ones. You begin to try and prepare yourself for that fact psychologically. Before I every considered this move a thought long and hard about how I would deal with and even I could deal with the loss of little ones. When you got ready for work that night I'm sure it wasn't with the idea of "I'll float to NICU tonight and learn what it's like to make a baby a DNR." For the parents making these discisions without the support of someone familiar with them caring for their child it is also difficult. You are a good nurse who did an admirable job but to have a familiar shoulder to lean on and cry on may have been easier for the parents. All in all you had a night passing through the flames. You have every reason to grieve, and feel the pain of the burns. I wish I had some magic words to help.:icon_hug:
  10. km5v6r

    My 4 year old daughter fixing to have heart surgery

    Talk to the Child Life department of the hospital you will be at. They have both the experience and supplies to help both your daughter and her schoolmates.
  11. km5v6r

    Telephone Orders- Perplexed in MA!

    :uhoh21: I am confused also. Once the orders are written on the chart what does it matter as to who wrote or notes them? Once they are written any other nurse may note or sign them off. Most of the time I will note orders on my patients but if I'm extremely busy someone else may note them. As the person noting the orders I want to know that the orders have been placed in the computer correctly, and transcribed to the MAR correctly. To my knowledge noting the orders means someone is aware of the order and it has been implemented. If I note an order for a CXR I know the order was placed in the computer. If it was an order for a med; then a copy of the order went to pharmacy and the med was written on the MAR usually with administration times assigned. When I worked in acute dialysis it was common for the charge to get the orders for the day from the physician and hand them off to the nurse doing the treatment to implement and note. Sometimes the orders would be called into one facility for a pt at a different facility. OTOH outside of an emergency I do not take orders through a third party. I have heard the nurse on the phone taking orders from a doc and implemented them before they were written ie stat CXR, stat EKG, stat lab ect. But the nurse who took the order is the one to actually write it on the chart.
  12. km5v6r

    fistula info for the non dialysis RN

    Wow, that is so helpful. It sounds like dialysis catheters should be OK to access for meds, but cannot be used during dialysis, is that correct? Prefered is to not access the dialysis catheter except for dialysis. The more times it is accessed the high the risk for infection and clotting of the line. An order to access the line can only come from the Nephrologist. No other physician can OK using the line. Special care also has to be taken to remove the Heparin and reload it after treatment. We used to use Heparin 5000 units/ml and a volume of 1-3 ml depending on the catheter.
  13. km5v6r

    fistula info for the non dialysis RN

    The tip of that catheter sits in the same place; the Vena Cava (superior or inferior) or the Rt Atrium. In dialysis the port that pulls blood from the pt to the machine is refered to as the arterial side and has a red end or cap. The blue is the port that blood is returned to the pt through and is refered to as the venous side of the tubing or catheter. The signficance come in with the end of the catheter. The red lumen is generally shorter then the blue lumen and terminates with holes on the side of the catherer proximal to the end. The blue lumen generally has holes at the tip of the catheter. During dialysis blood is pulled from and returned to the body at the same time. Two seperate lumens with different termination points helps to reduce the amount of recirculation that occurs. The goal is to pull the blood "upstream" from where it is returned. We would ask if the catheter had to be accessed for IV's or blood draws that the blue or venous port be accessed. The additional accessing will "gunk" up a line. It is much easier to push blood back through the port with the "gunk" then it is to pull blood from the "gunked" port. You will get only venous blood either way. Hope this helps.
  14. km5v6r

    Question About Renal Tranpslant. Help please.

    Your pt has a decrease in renal function. It maybe temporary or permanent. Contrast and antibiotics may cause a bump in the BUN and Cr as well as dehydration. Ironically enough the antirejection meds given after transplant are also nephrotoxic. A GFR of 60 still 10 yrs post transplant is really very good. Dialysis is considered necessary when the Cr clearance is down around 12-15.
  15. km5v6r

    You Know You're an Old(er) Nurse If . . .

    The only gloves on the unit were in the treatment room and it was locked at night. Treating skin breakdown with a brisk massage to improve the blood flow. Manual B/P's. Mercury B/P machines (no I don't remember the real name and can't spell it anyway) attached to the wall. Sliding a bare hand under a sleeping pt to see if they were wet. Treating that wet pt's excoriated skin with Maalox. Demerol/Vistaril and Atropine IM on the floor 1 hour before OR. Admission the afternoon before for morning OR. 12 lead EKG done with conductivity paste and suction cups. Saline pads on the code cart to place under the defibrillation paddles. Tap water enema's until clear at HS and in the AM before the barium enema. Followed by enemas after the test. Emptying pockets at home only to discover supply charge tickets. Assigning admissions not only on male/female but smoking/nonsmoking. Parents of peds pt sent home at 8:30 PM. Hand cranking the head of the bed up or down. Blocks under the legs on the head for trendlenberg.
  16. km5v6r

    Policy on IV tubing/bag change?

    Tubings at my hospital are changed every 96 hours unless it is Albumen, Lipids or Propofol. Manufacturer mixed IV's are changed every 48 hours, again, except the previous, and pharmacy mixed IV's every 24 hours. The unit has bright colored labels stating "change on Tuesday" etc. There is a different color each day. It is much easier to tell at a glance if the tubing is due to be changed and increased compliance with labeling.