klm49

That depends on what state you work in. Here I have work a specific minimum number of hours in a position as an RN as well as complete the necessary CEU's to have my license remain active. If I don't have the required number of work hours, the CEU requirement jumps dramatically. My license has been randomly audited twice now and both time my employer had to send a job description specifying the level of license required for my position and verification of the number of hours I had worked, to the state. Since these are the requirements for an RN, I am assuming they are the same for an LPN. Money and CEU's aren't enough here.

I work in Acute Dialysis. We regularly go through periods of feast or famine. We also have to decide who has to stay after hours to finish off the day. We try to keep it simple. The sequence we use was agreed to by everyone. 1. PRN staff are called off first 2. Anyone already into overtime is called off next 3. Hours worked versus days left to work that week...who is most likely to end up in OT by the end of the week 4. Part-time staff 5. Volunteers 6. Who was reduced last. They are the last to be reduced now. Our unit clerk is able to pull the hours everyone has worked that week and uses the schedule to calculate how many hours each person has left to work before hitting overtime. That way the person with the least number of hours/day left to work that week is called off first. The beginning of the week is always more difficult as most of us don't have many hours in yet. It isn't a perfect system but it is the best we have worked out and one everyone as agreed is the best compromise for this week at least.

One thing to keep in mind with all of this, is that anyone can sue for ANY reason. All it takes is an attorney to accpet the case. The act of being sued does not establish liability. To be held accountable and liable by the courts is another matter and requires a judgment. The question to look at is how many times has a lawsuit been successful and what were the circumstances? Last I read about; and it was several years ago; a judge dismissed a case brought against a medical person who acted as a first responder at an accident. The first responder was accused of moving the victim in an inappropriate manner resulting in worsening paralysis. The judge stated at that time that the Good Samaritan Law must be up held. If the law were not up held and precedent was allowed, no one would ever respond or stop to help. Even though the first responder SHOULD have known better; they acted with the intent to help not harm the victim and believed the victim to be in immediate danger. While additional damage was done by the responder; the responder was not liable for that damage. Part of the decision was also based on the fact that the responder was not receiving or expecting to receive compensation for the aid given. What is comes down to is not how likely is one to be sued but how likely is that suit to be successful? I think I will go research that one for myself.

Much to my horror, yes. Not always on the night shift either. I do Acute dialysis and do many treatments at the bedside. Quiet, over hot isolation room, isolation gown and mask, sleeping patient, call the night before.... Whiplash from jerking awake. At that point it is pace the room and a cold wet wash cloth to the back of the neck. Doing a bedside tx alone in an isolation room for 4 hours is difficult at the best of times. When you are pushing 18 hours straight on the clock you can count on micro sleep at the least. It is nice to say that caffeine is the answer except I can't leave the bedside. Not even to pee. Caffeine is a diuretic and my kidney's do work. Reality is that sleep is going to happen. No one is exempt. The natural tendency is to be awake during day light and sleep when it is dark. I worked night shift for 15 years. I would of told you I was a night person, couldn't function during day hours, had all of the tricks for day time sleeping down pat. I found otherwise when I changed to job to working the dreaded day shift and went over a year without so much as a cold. The most important thing is to acknowledge you are at risk, and to know when you are dealing with micro-sleep issues. Driving home and not knowing how you got there is not funny. It is life threatening for you and others on the road. Those who say "That could never happen to me. I wouldn't do something like that..." Are in denial or lying to themselves. It happens to all of us despite everything we do to prevent it.

For the standard AHA BLS class, once your certification has expired you have to retake the complete class. Yes, it seems punitive and some instructors will admit it is punitive and meant to remind people to take the class before expiring, but a line has to be drawn somewhere. You won't be the only one who is retaking the initial class because of an expired card. Check with your hospital before doing the on-line class though. My hospital won't accept on-line BLS. I have to renew my PALS certification this month. The hospital has 1 PALS renewal class per month. The Aug class is Aug 30. The July class was full and I couldn't get in because "your not due yet." If for some reason I can't make it to that class, I'm screwed. Of course, this is the only class the hospital will pay for. Taking it somewhere else earlier in the month is not an option. UGH. I hate putting these things off until the last minute.

I have been reading the excellent post regarding blood administration and dialysis and thought I would add to it. Before becoming an Acute dialysis nurse I worked nights in ICU. Dialysis was something that happened occasionally during the day but wasn't something I knew well. One thing that I didn't understand well enough in those days was what dialysis could and could not do in terms of fluid balance. The only fluid that can be removed from a patient is that which is in the Intravascular space or within the blood vessel it's self. A patient may have pitting edema up to their waist and still be intravascularly dry. Many times presents as low B/P, low CVP, tachycardia etc. Patient's will shift fluid into the extravascular space or 3rd space fluid for a variety of reasons. Dialysis can not touch that fluid until the patient shifts it back into blood vessels. Sometimes the Dr will order 25% Albumen, PRBC's, Hypertonic saline etc to help shift that fluid from the extravascular back into intravascular space. These are usually very short term fixes and may exacerbate the existing problem. We will occasionally get orders from non Nephrology services wanting us to dialyze a patient with pleural effusions or increasing acites. I will try, but it's not going to work. The real challenge comes in when the patient is septic on multiple pressors, has a serum Albumen of 1.2, and pitting edema up to the arm pits. Everyone wants dialysis to come in take some of the extra fluid off and "fix them". Without a decent B/P fluid removal or ultrafiltration becomes next to impossible. I keep telling them "give me a B/P and I will be happy to take off fluid." Until that patient has a means of shifting the extra fluid from the tissue back into the blood vessel dialysis can't touch it. I hope this helps someone.

The question keeps coming up in my hospital as to how fast we can give a unit of PRBC's during a dialysis tx. Traditionally we have infused 1 unit of PRBC's over 20-30 min into the Art chamber with continuous monitoring of temp and vs q 15 min. We also calculate the vol of the blood into the total UF goal. Dialysis is one of the only units in the hospital that blood bank will release 2-3 units of PRBC's at the same time to, simply because we can give the blood so quickly. Some of my newer staff have begun to challenge this and question the possibility of missing a transfusion reaction. Of course the hospital also wants evidence based practice. It is very difficult to find anything other then opinion on the internet so far. So what does your facility do? Any suggestions for reference sources?

I spoke with my Acute program Medical Director and said he had read of doing Hemodiafiltration in chronic units in other countries but wasn't sure how it was done. His question was much the same as mine in How do they do it? How do you give that much replacement sol during tx? How long are is the tx? What kind of filter do you use? Sorry I can't help but it would be interesting to learn how it is done.

There is a trick to holding pressure. My employer still uses the SureSeal band aid type dressings. I know not everyone does because of cost. Without the band aid I remove all of the tape. I don't want the tape to hang up on something or prevent the safety device from fully engaging. I then place a gauze folded into a small square over the needle site. I put my middle finger on the gauze and have my index finger straight to catch the loop and slide down the needle guard while the needle comes out. I hold pressure with one hand and actually pull the and engage the safety guard with the other hand. No pressure at the site with the middle fingers until the needle is out then firm pressure directly on the site with fingers 3 and 4. If it is leaking immediately, I shift my fingers slightly for more direct pressure. The biggest thing for me is NO PEEKING. Firm pressure without letting go for at least 3-5 minutes. Then carefully lighten the pressure on the gauze to see if oozing starts before moving the gauze completely. I always become impatient and try to "peek" it is time. I hope this helps.

I think we need a definition of terms. From the difference in the spelling of hemodialysis my guess is you are not practicing in the USA. How and when exactly are you doing HDF? The only time I have seen hemodiafiltration mentioned is with CRRT and then it is referred to as CVVHDF. Since CRRT is typically a 24-72 hour therapy done in ICU, lab is drawn frequently and adjustment made as needed. For our CRRT patient's, lab is only drawn from a central line or A-line. We don't consider the replacement fluids infusing pre or post filter as having impact on the systemic lab drawn from the patient. What are you using for replacement sol? I would think lab drawn from the patient other then the dialysis circuit would be an accurate reflection of the pt's lab values and should be treated as such.

I am extremely frustrated right now and just need to blow off some steam with others that will understand. My daughter called me at work on Wednesday last week and told me my 69 yr old mother had fallen in the bathroom, hit the bathtub and possibly broke her arm. I immediately found someone to cover for me and was dashing out of the hospital when my brother called that he was already on the way to the local ER with Mom. I spoke with Mom and she couldn't/wouldn't tell me how she came to fall. "I don't know what happened I just ended up on the floor." She adamantly denied hitting her head, dizziness etc. Unfortunately, I listened to Tim and Mom that they could manage the ER and went back to work rather then continue on to the hospital Mom was going to. Leaving work at that point was causing a major delay in treatment for patients and hardship for my co-workers. Tim called from the ER later and said that "Yes the shoulder was broken." Mom was sent home with pain pills and instructions to find a special type of arm immobilizer because she couldn't tolerate the one from the hospital. Tim dropped Mom off at home and I left work to hunt down the special immobilizer and brought it and the pain pills to Mom at home. Mom kept complaining about her shoulder blade and ribs hurting but otherwise said she was fine. Over the next couple of days Mom took the pain pills around the clock along with NSAIDS. She became more lethargic and confused but would rouse and argue strenuous about going back to the ER or Doc. I did take her to the Ortho Doc on Friday just to be sure everything was OK. He changed Mom's pain meds to a weaker narcotic because even she admitted she was loopy at times. I thought since Mom is totally narcotic naive the Percocet were maybe to strong. Saturday my daughter called me at work again because Mom was totally "out of it". I sent my brother over to check and after arguing with Mom for an hour he convinced her to go back to the ER. This time I did leave work and met them in the ER. Mom's SaO2 on room air was 78% and that was with her sitting up, arguing and awake. She had been drifting out in mid sentence at home. I don't want to think how low the levels were when she slept or drifted out. It seems when she fell on Wednesday she fractured and displaced ribs 3-9 on the left side along with fracturing her left humerus. The first ER Doc didn't x-ray anything other then her shoulder. It is a miracle she survived to make the second trip to the ER. Mom has been a 2-3 pack a day smoker for 50 yrs. Needless to say she is a COPDer. How does an elderly patient come to ER after falling at home with no explanation and not get a full work up? Honestly, I thought Mom would have virtually glow in the dark from x-ray's looking for additional trauma and possible causes of the fall. She so easily could have had compression fractures of the spine, neck injury, hip injury, head injury, etc. Not to mention why did she fall in the first place? She had a cerebellar CVA last Dec that affected her balance. How did they know this wasn't a repeat of that CVA or a cardiac arrhythmia of type? Mom was admitted from the ER the second time for pain management and aggressive Pulmonary toileting. The second ER doc told me that the number of ribs broken with the arm fracture would have justified admission to the hospital on the first visit. While in the hospital I did have some discussions with the case manager about how unhappy I was with the first ER visit. I was assured it would be report to QA and the manager of the ER. Verbal reassurances that action would be taken is all I got. In other words a brush off. I am tempted to e-mail and request additional follow up. I work for the same hospital chain but a different campus then what Mom went to. Would it be inappropriate to e-mail the QA person; whose name I was given; explain who I am and request more information on the follow up? I am a dialysis nurse. I have never worked in ER. Are my expectations of the work up Mom should have received the first visit unrealistic? Those few days Mom was home between the accident and being admitted were horrible. Mom was in severe pain, argumentative, and needing help but reluctant to allow it. I was up and down all night checking on her, toileting her and taking the cigarettes away. It was such a relief to come home and sleep several hours straight the first night she was in the hospital because I knew someone else was watching her, helping her and she wasn't smoking. Thanks for listening. Being a part of the "Sandwich" generation sucks. Especially when it goes from simple "Sandwich" to special "Panni" generation.

I worked a Dialysis at Sea cruise this past fall. I did a 7 day cruise to Alaska. It was alot of fun but also hard work. The pay for working is that the cruise is free. On ship you are treated as any other paying customer and have access to all of the facilities and activities. Any thing that others have to pay for ie drinks, shore excursions etc. you have to pay for. The room was one of the nicer cabins with a port hole looking out. We met all of the dialysis patients on the ship the first day. Treatments are done on the "at sea" days and patients are assigned a specific time for their treatment. The dialysis area was a part of the ships hospital and very crowded. We could dialyze 2 patients at a time in 2 different rooms. We had a bed and a chair in each room with 2 Fresenius K machines. The trip I took had 11 dialysis patients on board with 3 RN's. Technically we should have had one more staff person. One nurse who has cruised before is designated as the Charge nurse and manages the supplies, schedule etc. Patient's bring there meds. The rest of the supplies for several trips are packed into large totes in the dialysis rooms. A nephrologist is on board and rounds on all of the patients. The outpt units send kardex's and copies of past run sheets. The pt's are required to have some type of trip insurance in case something happens and they need to be put off ship and transported back to the main land or home. As dialysis nurses we were responsible for pt care only while the pt's were on the machine. All other time was our personal time to do as we wished. Since this was my first trip I traveled alone and was assigned a cabin with one of the other nurses. She had done several trips and was great source of advise and tips. My 7 day cruise left on Saturday, we dialyzed people on Sunday; a 17 hour day as we figured out the routine; then again at sea on Wednesday and Friday and disembarked on Saturday. The ships do have a lot of activities to enterain the guest for the at sea days that I could do as I was working. Late nights were out too as I was either getting up early for shore trips or starting patients at 0430-0500. The patient's had a blast and appreciated being able to travel; many with their families. I do hope to do another trip this next year but the staff openings do fill quickly.