jlautier

patients always have high bp's in HD.. i wait until it gets lowered as they UF to give it, and generally our docs don't care about the warning and feel the benefit (managed anemia) out ways the warning on the EPO box. I mean if someone with a hgb of 8.0 and has a high bp...wouldn't they benefit from the EPO? its a discussion with doc, and never feel bad to call ask. They went to med school, we didnt, get them to own it. than you can write a note on the HD flowsheet. "OK to admin EPO despite BP of 220/110 per MD So and so" CYA. ALSO if you feel you must hold.. the patient can get the missed dose the next HD treatment. its a weekly dose that is broken into 3's; so that dose can be rescheduled--applicable to other situations such as: patient skipped Wednesday, had 10,000u EPO due. Rookie nurse says well they skipped.. whatever less work today thank god i can catch up on stuff. Veteran RN: Well the dose can be admin on friday w/ their scheduled dose of 10,000 for a total of 20,000 units. Let me follow through and make sure the patient gets their EPO so they ain't anemic because anemic patients feel like crap and may feel to tired to come to HD. (again, MD must be on board, but they will LOVE you for following up like this). hope this helped!

1: Needles remain in till the treatment is done; patients who get restless and bend their arm hand a chance at infiltrating. What happens is similar to a peripheral line except the instead of a rate of 100cc/hr; its 500cc/min; and a massive, painful, hematoma forms and the fistula needs to de-accessed and rested before the next treatment. 2.When patients are cannulated correctly, the needles flash back; if an HD RN is in doubt of placement, a 10cc syringe can be connected and the line flushed. IF met with resistance; the needle needs to be readjusted. hope it helps!

I want to elaborate on the HD perm catheters-- You are correct, it is a CVC like any other CVC. heparin dwells at 1,000units per ml, so don't get freaked out. The reason why nephro docs and HD rn's alike tweek about using a CVC that was inserted into a patient for HD is because we want to limit those who access it to ensure that CVC is patent, not infected, and also persevered for hemodialysis only. Key here is without that CVC the patient would not be able to get dialysis, they would need another line placed if that one gets infected or isn't properly cared for. That is why nephro people tweek if you say.. "Can't i just draw that CBC off there CVC, have you tried getting blood out of this patients veins, my god, its like so impossible" chances are the person has a CVC on chronic HD because they have serious PVD and AVF or AVG creation is impossible. To recap, those CVC's are to be left alone. Caveat--if you see a soiled dressing as indicated above, contact the nephro on-call, say, "The patients HD CVC dressing is soil and falling off, I wanted to check with you because we don't ever touch HD accesses, but I want to change it because it looks gross AF" ^^every doc will say, change it, thanks for calling. evening if its the night on-call person. and if they get upset, you say.. "i don't want them to get septic doc.. jeez."

its hard to do any nursing when sh*t is hitting the fan at your clinic. Nursing skills you speak of sound more like "tasks" urinary catheters, dressing changes, wounds, etc. Those are all tasks. Nursing skills are assessing patients and keeping them safe. those translate to any unit (non-dialysis). you can learn tasks at any age, patients manage tasks at home w/o nurses to help them. Dialysis nurse stuff i have done in a chronic unit: manage anemia; adjust doses of iron and epogen w/ an algorithm (assess patients for anemia--i can spot an anemic patient a mile away), staff scheduling--a valuable tool, managed mineral management w/ zemplar/ hectrolol, worked w/ dietician to improve patients lab work to met goal, EDUCATE the sh*t out the patients so they stop drinking dark soda's and oranges. What CVC's sites for infection, i can spot a septic patient a mile away; get an order for vanco, draw troughs, adjust the medication. You got experience if you look for it. Once your clinic gets a good work flow goin you can start to do more nursing stuff and think less like a tech and just to get the patients on and off the machine. the big butt here is: you need to make it your experience. If you just pulling fluid of patients than you need to reevaluate what your doing. What comorbids do your patients have? how does that effect the treatment you are giving them? I worked free standing for 3.5 years; floor RN -- charge RN; anemia management, mineral management, scheduling (patient and staff), loved every notch in my belt. I left for an acute dialysis gig w/ a large inner city hospital that is owned by the hospital--a learning curve to the cardiac monitor and some other acute care things giving insulin, titrating heparin drips (sorta like the vanco troughs or epogen i used to titrate outpatient). Dialysis is rewarding but you can only make as much as a difference to your patients as your willing to seek. You ever get a patient worked up for transplant? thats case coordination, in my 3.5 years, 5 of my primary patients got transplants. you can rock it !

worth it only if you want to be an educator... no requirements at FMC to keep working, FMC doesn't assist w/ CEU cost... so screw it. it can help w/ the CAP advancement but if your charge nurse you prolly are doing enough to be an RN 3 and get the pay you deserve (and if ur not RN 3 yet, talk to your manager and get it--don't need a CNN for that). I don't think its worth it the money. You are better off goin to college and getting a clinical nurse leader masters degree and be the boss of all the educators or work in a different setting. You see what im saying? I bailed on FMC and work at an non-profit dialysis center now. loving it. kodus on your dialysis growth!

Exactly my point--you would want to check the ECG before dialysis. Following treatment, a patients K, Ca, and Na will be that of the Acid used for tx. This could hide a patients underlying rhythm. So to answer this posters question, check before not after.

ECG measures electrical activity... a high K will have implications to the ECG.. widened QRS.. more K competing for bonding sites. So TBH it does make a difference because every patient post dialysis will have a similar ECG because the blood electrolytes will match that of the dialysate until the body can diffuse more electrolytes from the interstitial space to the vascular space.

Similar to why if you forget labs you can't draw mid treatment. Prior to the blood hitting the dializer, the patients blood is untreated and a better indication of what a patients labs are like. 2 ECG's on the same patient will look different; QRS complex will be pointy becuase of a higher K+ pre than post treatment. Thats a small example. Post treatment patients K's Ca's and Na's will be what ever the dialysate level of those lytes are. 2.0 K bath 2.5 Ca+ bath for example. The body will diffuse into the blood stream slowly between treatments and increase those levels. So a pre ECG will show a patients true rhythm because the lytes wont be altered by the treatment.

If the patient has a CVC, recirculation will always occur because the tips of the catheter are only .1 mm appart from each other. Especially if the catheter is running reverse than a higher percentage will be recirculating during the tx. That small space between catheter tips in the atria also make it difficult to achieve an adequate BFR. With an asymptomatic patient I would assume the patient's system was beginning to clot. What was the BFR, DFR, KECN's, and spkt/v for this treatment? Was the patient meeting adequacy? (green light) ?

One time a patient had a cardiac arrest--not on treatment or at the unit--he was revived and his K was 8.5. He was dialyzed and his since returned to the outpatient setting...after a CABG x4. He told me he thought he was eating clementines--but happened to be oranges. He ate 3 of them. Then literately dropped dead a few hours later. These are the most frustrating patients, HD hx of 4+ years... and you are going to tell me you can't tell the difference between an orange and a clementine, and who told you you can have more than one in between treatments? There is less K in in clementines vs oranges. The patients know the dietary regs but still make poor choices. They are told 1 and they think 100 is ok. Doesnt matter the units either... K or mL. LOL

No matter where you start working, give it time. I've had doubts too. It gets better. Push through!

Keep the job, broaden your search. I was there too. We all take a tour. Be a model employee. Patients first. Outpatient dialysis is the way I got out. I worked my way into acutes, and now work at a hospital. Good luck keep the faith! Organize yourself there; use your census to remind yourself of any 12 pm or 2 pm meds. And finger sticks too. LTC is only a med pass, that's why LPNs work there. Trust me. It's hard because of the volume. The only thing that helps in ltc is popping the same pills for the same patient everyday. That's how it gets easier. Don't focus in on a hospital, keep searching for jobs. Use your networks, your friends, whose short ? Who needs a body? Good luck!!

I too worked at a LTC facility immediately following graduation from school, even with my BSN i found it difficult to land a job in a hospital. I found the LTC place to be unorganized, unsafe, and not a place for a new grad. Luckily, i received a call from one of my friends who worked for a large dialysis company, said i should check it out. Since then I have left my LTC place and been working outpatient dialysis for almost 3 years. I love it. CKD comes with so many comorbids... and the nurse needs to be in tune with each patients medical history in order to provide safe treatment. You'll get it. The training i received was 3 months long, i felt ready to work the floor once i was completed. I now take charge, precept, and love every day I am at work. your shadow experience really will be a peer interview, not about skills but about personality. Its a close knit family, at least at my center, and you need to jive with the people working there or else it can affect the unit's flow. Just be yourself, good luck! --Currently enrolled at an APRN program, want to specialize into a nephrology APRN. My company pays 4,400 year... reimbursement. cant be beat!

CT: it's 10 pts to 1 RN w/ 2 CCHT or 9:1 w/ 1 CCHT and 1 PCT. Typically we turn over 4 machines a shift per staff member tho.

Diuresis: increased production urine d/t a medication to increase urine production. Polyuria: is a symptom.