KAT1994

When you insert the needle bevel up it creates a narrow flap/slit. When you remove that needle it leaves a small opening because the flap/slit edges go back together edge to edge. If you flip the needle, then when you pull the needle out it actually cores out a peice of the graft or fistula. Flipping the needle back before you pull it, or the initial flipping can make the hole larger and cause trauma to the vessel or graft wall. I have to admit that I have had times when the only way to advance the needle was to flip it. I absolutely try to avoid it, but sometimes it comes down to the pt dialyzing or not. The two dialysis companies I have worked for it is against policy to flip the needle.

Which book and study guide did you use to study? I bought a recommened book, but I'm not sure it is the most helpful. The Nephrology Nurse Core Cirriculum or something like that.

Just curious if any of the chronic units out there replace the ends of the tunnel catheters when the become cracked? We send the patient to the interventional radiologist, but they are wanting us to do it in the units. I don't think this is very safe. We have a very busy unit with tight staffing ratios. On the other hand, sometimes getting the pt scheduled for transportation, getting an appointment with radiology, and rescheduling a dialysis tx can take a huge amount of time and the delay in dialysis can be dangerous for the patient. What do you all do at your units?

I use a very light tourniquet or use my little finger to apply pressure. This helps to inflate the inner diameter of the fistula and helps to reduce the chance of infiltration. I have had a few fistulas, especially upper arm, that when you apply even a light tourniquet it will shift the fistula to the side and infiltrate. This has been mostly with new, immature fistulas in the upper arm,and pts with flabby upper arms. I really encourage the PCTs to use finger pressure if possible.

At our unit we have standing orders: K+6=1k w/a stat re-check the next tx, MD, and dietician are notified. We only move up or down one bath; for example, k+ of 3 goes to 5.4 they are only moved to a 3k instead of a 2k bath. I would probably re-check k+ in a week or two. Our dieticians work with the pts very closely and for the most part they don't fluctuate that much. We check labs at least once a month.

Dialysis becomes very hard when you feel like you are doing it to the pt instead of for the pt. When our unit has a heavy care pt like this one we usually require a caregiver to come with the pt. The pt sounds like one that would have a full time caregiver. Is he from a nursing home? We also have mobile screens we can put up for privacy. At our unit we also do not allow any dialysis in beds. If a pt is not stable enough to dialyze in a dialysis chair, then they most likely are not stable enough for the staffing ratio of a chronic unit. Does your Center Director have any concern for infection control if the staff is cleaning up stools, resp. sx, any uncontained wound drainage? Chances are this pt is colonized with very resistant bacteria. For the other pts, I hope the CD has taken steps to control infection in the unit.

I usually put on 3 or 4 of the patients so that we stay on schedule for turnover. I help with rounds while each PCT goes on break ( a total of 90 min). So while I am passing meds and doing dressing changes I am also answering the phone, doing rounds, supervising PCTs, trying to keep pt med lists, and charting current. During turnover I usually take off 3 pts and put on maybe 3. Turnover 3 machines. do all of the pre/post assements. By turnover, there is another RN which leaves me with 11 pts to take off and 11 to put on with 2 PCT. We have 30 min after a catheter comes off to have another pt in that chair and on the machine. 40 min after a stick to have another pt in that chair and on the machine. When we get down to 7 pt a PCT is to go home. I am exhausted at the end of the day. Now my CD wants to make me salary since I am frequently still trying to finish my paperwork two-three hours after my shift. I am also the Vascular Access Coordinator for our unit with 75-96 pts. I am feeling a little abused. My own fault I suppose.

I recently had a similar problem. We started by reducing the heparin. He actually is down to a 2k bolus and that is it. He continued to have bleeding so we sent him for an ultrasound. He had central stenosis and had an angiogram, but still had problems with bleeding. We started using button-hole technique and have only had two episodes of bleeding during the initial establishment of the button-holes when we were still using sharp needles. He has not had anymore bleeding since then. We have been using this for two months now. Another pt we found that her skin is so thin over her AVF that if we stick directly over the top she bleeds profusely, but if we stick slightly on the side she has no bleeding. (She doesn't have a pseudoaneurysm)

Our chronic hemo clinic has had a sudden lower patient census so the shifts have been rearranged. Usually we have one RN to 12 pt with 3 PCT. 11 pt one RN and 2PCT. 7 pt one RN and one PCT. Right now I have been given upto 15 patients with three PCT. Granted, all of them are stable except for one who is on IDPN. Five of the pts have catheters which the PCT can put on, but cannot change the dressing. Since I am the only RN for the first 3.5 hr I handle most all of the issues that arise. I am usually a very organized nurse, but I am having quite a time. Does anyone else have similar patient load?

I have worked med-surg, telemetry, skilled nursing home care, and now chronic hemo. I have never worked in acutes, but I think generally you have fewer patients to focus on at one time and the care is more focused. It may depend on what part of med-surg was so stressful for you as to whether or not acute hemo would be an improvement for you. Can you work indepentently and do you have good critical thinking skills and assessment skills I would think these would be very important if you will be the only dialysis nurse there at times. As a newer nurse, do you feel comfortable taking care of unstable patients for four hours while they are even more unstable while they are dialyzing? For me, the nursing home was the most difficult of the areas I have worked in. You get very little respect and response from the physicians compared to the hospital. It is very difficult to deliver or supervise the delivery of quality care to maybe 25, 50, or even 75 patients. I really missed the patients when I left, but I couldn't stand the poor standard of care for the patients and unsupportive management. The job is literally back breaking physical work and the majority of the time the turn-over and call-ins are high so you work short-handed. At my chronic unit we are the "home unit" for the acutes program. I rarely see them looking very stressed, unless they get a sudden influx of admits. I think that the chronic unit is the easiest and most rewarding of the nursing jobs that I have had. I also think that each of the areas I have worked has been very useful experience and I have no regrets. I would try to spend some time talking to other nurses that actually work in the places that you are thinking about working. Questions like... How often do they not get to take a break? How supportive do they feel the management is. How long have the other staff worked there. How long is the orientation? I hope this is helpful. Good luck!

Hi, I'm new to allnurses.com. I know this is an old post, but just thought I'd share my similar experience. Two years ago we had 75% catheters in our 86 pt unit. Our PCTs could not do catheters at our unit although it is permitted in my state. I had 9 catheters, 2 lifesites, and one fistula pt. It was CRAZY! The techs would have the pts completely ready to be put on except for the assessment. I would only have to assess and initiate or DC the tx and the techs did all the fluff and tuck. Thank God things have changed and I would NEVER do it again. Things changed when we got a new CD. She would be there, even on a Saturday, during turnover to help for a few hours. Also, I became the Vascular Access Coordinator. We are now down to less than 15% catheters that are not candidate for other access and 11% in the process of maturing fistulas or have referral for fistula placement. Fortunately, we also set up a program to train a few exceptional PCTs to do catheters and check them off on their technique every six months.