perksrn

Dialysis nursing intrigued me. I am in my forties and had been in the same area of nursing for quite some time. I wanted to stimulate some brain cells and learn something new. I had no idea what I was in store for. Hopefully, sharing my experience will provide some insight for nurses interested in making the change. So, why is dialysis so different from any other area of nursing? 1. Take what you learned about a "stable patient" and toss it out the window. When I started in dialysis I continued to uphold my standards of best nursing practice. I wanted to call the physician when a patient's blood pressure was 200/100 or 86/50. What I once considered a critical lab was a joke to my coworkers. I had to relearn "normal lab values". ESRD patients are a completely different form of stable. Learning your patient is essential in determining when to call in the cavalry, when to monitor and when to call it "all good". There are many determining factors and a dialysis nurse is one part nurse/one part detective. A patient can walk in the door in hypertensive crisis and within hours you might be throwing their chair back to bring their pressure back up. It's a fine recipe of patient history, medication timing, knowing how much fluid to take off and how quickly, patient education and several other treatment tweaks. This can be a benefit of dialysis nursing as you become more experienced. It's rewarding to be such an integral part of improving the patient's treatment and symptoms. On the flipside, it can be a disadvantage when you have a difficult patient who doesn't seem to respond to any of your tricks. It can be quite challenging to play detective while overseeing patient technicians, answering the phone, rounding with physicians, passing medications and caring for 11 other patients. 2. The nursing model and delegation practices don't follow any rule book. I began my training with a patient care technician. These technicians do not necessarily have any previous history in the medical field or have any certificate or degree in a medically related field. They are trained on the job and have dialysis focused education provided by the company they work for. They are also required to pass a dialysis specific certification. This exam is not a piece of cake. The techs I work with are hard-working, can multitask and never seem to tire. I have an entirely new admiration for what we would refer to as "support staff" in the outside nursing world. What gives me pause is putting technicians in a position to make decisions based on task focused training. Many technicians do not understand why they do some of the things they have been trained to do and can not give rationale behind their practices. I quickly annoyed my techs while I was training. It was essential for me to understand the "why" behind the instruction. They felt I was questioning them or that I was a "know it all". What they failed to understand is how hard I worked for my license and how important it is to maintain it. If I am going to be held responsible for my actions and theirs I need to be sure the information being passed on is based on good practice. Many times the answer would be "because that's how I was trained." Some of the technicians understand the importance of reporting to the nurse. Others quickly make medical decisions for their patients without ever informing the nurse of the patient's condition. It is the nature of dialysis. The technicians are required to set up machines, cannulate patients, monitor vitals, administer heparin, take patients off of the machines and quickly prepare for a new shift of patients. They work very independently and with little or no medical expertise some do not realize the importance of reporting to the RN. In dialysis it is not unusual for technicians to train nurses, question nursing decisions, or to tell the RN what needs to be done. 3. Plan to wear many different hats. I enjoy being busy. I thrive on multitasking and thinking on my feet. Many days this is a perk of my job. It feeds my need to be challenged. Other days I feel that the dialysis companies are more interested in making money than caring for patients. When I was being interviewed I was told that I would be in charge of 3 to 4 techs. Each tech could have as many as 4 patients. I would pass meds, perform assessments, monitor treatments, round with physicians and perform QA. The real story? Many days it isn't in the budget to have a technician for every patient assignment. Unlike hospital nursing - if an aide calls out a nurse doesn't assume all of his/her responsibilities- nurses in dialysis take on that that technicians responsibilities, in addition to her own. Imagine this... You come in at 5 am. You are short a technician. Your challenges for the day.. Your morning responsibilities have just multiplied. You need to perform morning QA, set up a pod of machines, monitor what is happening with other patients as they arrive while cannulating and treating your own patient assignment. Machine checks are due within 30 minutes of treatment initiation for every patient. You must figure out how to care for your patients, without delay, while skirting over to the other patients to do assessments and machine checks. If any patient requires immediate attention you must leave your patients to care for another because you are the only nurse on the floor. If this delays putting one of the patients in your assignment on the machine the entire schedule caves. My fear in all of this is that by assuming technician responsibilities it is difficult to monitor the well being of all patients and be held accountable for the actions of your team. I am by no means too good to perform these duties. If all patients have an assigned technician it is ideal for the nurse to pitch in as time allows/where needed. It is difficult to prioritize when you are expected to take on the full time responsibility of a technician and a nurse. Imagine being in the hospital giving a patient a bed bath. How would you focus on that task while also monitoring your patients on the floor, responding to call bells, giving prn medications, speaking with physicians, etc? It doesn't work. It isn't safe. 4. Sitting isn't an option The hours pass by quickly. I like that. It is a challenge, however, to be on your feet for 10 to 14 hours. This is not unique to dialysis. Many nursing specialties share this in common. The difference in dialysis nursing/other specialties is this...When you sit to document, make a call to a physician, review labs no one looks at you as if you were goofing off. An aide or dietician doesn't approach you with a list of things they need help with. I've found at my clinic that if I sit down to perform these tasks I am almost always approached to help the technicians catch up. Again, I am not too proud to perform any task but I would appreciate the understanding that I am not a technician. Some nursing responsibilities involve documentation, monitoring, QA, review and communication with family and medical professionals. On a daily basis I delay these responsibilities until the end of the day to avoid conflict. I am usually at work for at least an hour after everyone leaves. That is a definite con. In summary I love the practice of dialysis. I would never question my decision if I were permitted to perform my nursing duties in a timely manner and truly be able to "charge". Being a charge nurse doesn't involve a power trip for me. It involves coordination, monitoring, communication and delegation. In dialysis non licensed coworkers are administering medications, making independent medical decisions and consistently dependent on the nurse to assist with their duties (not their fault as the expectations of them are high). Each day I struggle with the pros/cons.

I am having some frustrations at work. I have been in dialysis for 5 months/a nurse for 15 years. I am learning so much, which is why I changed specialties. I want to continue to learn and be challenged. I feel like my team questions everything I do as if I am new to nursing all together or I have no rationale for any decisions I make. The techs go behind me and ask other nurses about my decisions and the nurses change my interventions without speaking to me. I am a pretty thorough nurse but I find that more often than not the others cut corners and don't follow up on things I find important. They have indicated I need to let several things go. Two examples 1. Today a patient complained of pain at her fistula site. I looked at the site and it was extremely red and swollen. One nurse had told her just to put OTC ointment on it and another told her it was just from the topical numbing spray. I wanted to contact the physician but was dismissed quickly. 2. Here is the reason for the post. I have been learning about target weight, when to challenge patients, etc. My patient today has had increased weakness and pitting edema of +3. She has been educated on diet and home interventions. She has frequent gains of 5 kilos +. This week I got an order for an extra treatment. Today she came in after 2 days of consecutive treatment and was symptomatic. I got an order to challenge her by 2 kilos. My thinking/plan was to challenge her and if she could not tolerate it, reduce the goal. Another nurse went to my boss and changed my goal without speaking to me. I felt like I had good rationale as this patient has been declining and been symptomatic of fluid overload. Any advice or thoughts? When do you challenge patients?

Any advice on improving the tech/RN relationship?

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I'm a new RN to dialysis. This is an issue at our clinic as well. I see the nurses sitting idly by while they could be helping at changeover. I have vowed not to be that nurse. The techs are so incredible and work very hard. I have learned a lot from them. Our nurses often take "a pod". Generally it is 3 to 4 of their own patients plus charge responsibilities. That can be tricky. What I do have concerns about is that the techs have such an enormous amount of responsibility that they often don't realize the importance of reporting patient issues to the RN and some have little respect for the nursing knowledge we utilize to care for our patients. It's really the environment of dialysis that breeds this particular issue. I am constantly on the floor in my free time helping stock, change over, clean, etc but was recently accused of thinking I was better than the techs and not their equal as my boss expects. I don't really know what I've done or could do to change this perception. I think our techs are fantastic but can't change my opinion that we have different areas of expertise that should be recognized to best care for our patients as a team.

I consider myself a very reflective person capable of growth. I analyze my own behavior and look for opportunities to improve. This time I'm at an impass. Many times in my nursing career I've been accused of being a "know it all" or looking down on others. I can honestly say that every nurse, nurses aid, administrative assistant, etc has a lot to contribute. We all come from a different knowledge base and experience pool and can share our expertise to make each other more well rounded. I've soul searched this belief ensuring I'm not fooling myself that I hold this true. I've come to the conclusion that I wholeheartedly believe that. Here's where the trouble lies. I have learned to research and validate some things that I am told as a nurse. it isn't that I don't trust people but oftentimes in nursing misinformation gets passed along and we end up with some poor practices not even being aware. I look at policies, rationale and best practice to make sure I am protecting my patients and my license. I speak up if someone is instructing me to do do something that doesn't set right. An example... I recently changed career fields. In dialysis, techs are allowed to change CVC dressings. I have, in a previous field, taught this and infection control. As the tech was teaching me she corrected me on how to clean with Chloraprep. I explained why we clean in a back and forth motion. She scoffed at me so I tread carefully afterward...but..she then instructed me to clean the Chloraprep off with an alcohol wipe. So, I pointed out that we wouldn't want to wipe it off since it has antiseptic properties (she also "cleans off" Betadine). She was furious. I pulled the policy and ask her to review it with me. She said she didn't care what the policy said and she was going to continue to do it her way. This is an example but has happened to me more than once in my career. There are certain things that we can compromise on. If it doesn't impact patient care I'm willing to hear different methods. When it does change the game I try to explain where I'm coming from and ask questions. This is almost always received with defensiveness. I don't know everything, however, I know what I know. Has anyone else ran into this? Any thoughts/advice?

Four pts would be devine. Not to say it wouldnt be hard work, I know its always work. I am a new grad and within the third week I had 5-6 patients and 6-7 on nights. It has been so overwhelming that I don't know if I can handle it. We are required to chart 8,12,4,6 and any procedures and a free text note on each patient. AGGGH. Honestly I have started having panic attacks at night. It sucks.

Just the fact that you are reaching out and expressing something many of us have felt tells me that you are a survivor. You, like me, know when you can't do it (keep it all in) by yourself any more. I agree with some others who say you may just need to make a change in your life. Where does the most stress lie? Nothing is worth peace of mind. Cut back on hours, change floors, or jobs? I have been in the medical field for 4 years now but only recently obtained my RN (on med/renal). I have always felt like everyone around me knew more (even with a decent GPA and complements from others) When I get a complement, I think "boy, I sure fooled you" Confidence is a struggle, but sometimes we need to really listen to what people say to us. A complement is only wasted on someone unwilling to accept it. I am certain you have touched lives with your compassion. I have been MAXED out this week, so your post is timely for me. I have just started to take a full load on days and DO NOT feel ready or prepared. I hear IV alarms in my sleep (when I sleep) and constantly worry that I have forgotten something vital. UGH. Just know I am thinking of you and hope you find the root of your stress and move toward something more fulfilling.

I am looking for some info on med administration through G tubes. I have seen some nurses administer meds by gravity (which takes a long time, even with dilute meds) and others use gentle push with bulb or syringe. What's the nursing standard? If "pushing" with syringe, what's the best way to draw up to avoid the instillation of air and pt distention? Also on G tubes, what is the standard for aspirating, measuring and documenting residual. Some say only if ordered, some say q4. If you have info or a good website regarding this, I would love it. Thanks!!!

This week in general has been a blooper. I opened my mouth about all of the procedures I had not done and wanted to do before graduation...I think I got to do them all....Today, I planned, would be error proof. I was in my patient's room giving her meds via NG when my instructor walks in and says, "You did give the Dilantin p.o, right?" I just stared blankly at the tube watching the Dilantin go down...She got the clue and suctioned it out, clamped the tube and took me to the hallway. I could have cried. I had looked at the dosages and meds carefully, but ASSUMED they were all via NG. Dilantin was a new order and was p.o. (not sure why?) Of course, never assume....NEVER. She had me redo the meds...I am sure the patient was a little confused (I did give her a brief explanation)!

Will let you know about Raleigh. Hopefully there is a decent selection.

We are headed to Raleigh, NC this weekend. I'll try there. We only have one decent shop where I live. Thanks!

If anyone has suggestions on where to find a nice white dress for pinning, I would appreciate it. Everything I have found so far is thin, see-through, and cheap looking. If we have to wear one, I would like it to look nice. Ordered one that looked like a tent, so I sent it back. HELP! Nichole