Rookie mistakes in dialysis

[thelittlenurs]

Hello all,

I am a HD in an in-center dialysis center, I have been working in HD for 8 months now and feel that I'm doing well for a new HD nurse, still I know many challenges will present themselves. Anyway, what are some of the challenges you experienced nurses see with new nurses and some of the mistakes that should be avoided??? I forgot to clamp the saline bag once and never did it again, of course I was rushing to get patient on that time. I'm past the point of making careless mistakes and up to speed with machine setups and put on/off times. But I just know that as soon as I start to feel like I have an easy job, I'm proven wrong.

[Chisca, RN]

It sounds as if you have the tech part down, what about the nursing part? What is frequently lost in the dialysis factory is the nursing assessment. Can you tell if a patient has an S3 heart sound? Jugular vein distension and how much? Are you able to identify a patient's learning needs and point them to the right resources? In the acute setting 50% of patients discharged do not understand their discharge instructions. If you haven't already join ANNA and join your local chapter. Good luck.

[thelittlenurs]

Thanks for your reply! We have these flimsy crappy stethoscopes, one for each machine, I am able to hear bruits well and lung sounds, but for some of the more obese patients I can barely hear heart sounds. They don't want us to use our personal stethoscopes for infection control purposes. Yes you're right I need focus on my nursing skills as an HD nurse. I was surprised to see that our previous charge nurse was running the Vancomycin infusion fast !!! Im like have you heard of redman syndrome??? I realized some nurses do not have experience in other areas of nursing but I'm sure administering Vancomycin over 60 minutes was a question on our nursing board exam. Also, I haven't found a policy that states Epogen should be held if BP is high, do any of you know where I can find the literature about the effects on blood pressure from IV Epogen administration?

[StarBrownRN]

The effects of Epo on blood pressure is in the medication's prescribing info. Hypertension is one of the side effects in patients with CKD/ESRD. You can visit the manufacturer's website for a copy of the prescribing info. Epogen has many contraindications and serious side effects.

[Gladimadeit]

For real on that education stuff. A fairly smart guy showed up for treatment with almost no information after being discharged from the hospital. Imagine his response when we told him he needed to stay 4 hours.... and come back three times a week.... for the rest of your life...í ½í¸ í ½í¸¡í ½í¸¤

[thelittlenurs]

I read them now , but it is still not clear to me whether the patient should not be receiving EPO due to uncontrolled hypertension or just held if the patient has a high blood pressure episode. I have a patient who comes in with high bp consistently and stabilizes toward the last hour of treatment, I give it then, but would this mean he/she shouldn't be receiving EPO at all? The nephrologist and NP are aware that this pt comes in with high BP btw.

[Squidelle]

Epogen shouldn't be given if you have uncontrolled HTN. Pts BP will understandably be high before HD especially since lots of times BP meds are held until after HD.

[GeauxNursing]

Our clinic had standing orders for BP notification to dr as well as holding epo, or giving prn clonidine.

[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!

[Twinmom06, ASN, APN]

For real on that education stuff. A fairly smart guy showed up for treatment with almost no information after being discharged from the hospital. Imagine his response when we told him he needed to stay 4 hours.... and come back three times a week.... for the rest of your life...������������������

Coming from the acute side (which I am) that's a travesty and SHAME on the nurses that took care of them in the hospital. Even our docs (which are in 3 different renal groups) review that with the patients. I'm wondering if the patient heard what he wanted to.

[MsMort]

Sorry. Not ALL patients on dialysis have hypertension. Remember that patients are all individuals and need to treated as such. Leaving standing orders and nor reviewing them can put our patients' lives and futures at risk. Never assume.

[AlabamaBelle]

I work in the Acute setting and recently had a PD patient who had several other problems. His wife was at bedside and he was sleeping. She revealed that she felt like she had not been educated well enough prior to the placement of the catheter. She said she would not have done it because she felt uncomfortable with any "nurse" like thing. She was terrified! I let her e press her feelings and suggested she speak with his clinic nurse. Never felt so helpless.

I've also picked up patients from other teammate. One of the patients had a UF goal that could have killed him. He's compliant, not big gainer. Immediately I decreased his goal, which was close to where he was. A few minutes later he complained of cramps, so UF turned off. Cramps quickly resolved. We are generally ordered "max fluid removal." Sometimes some teammates get a litte aggressive, even with BPs not high, so the BP is not the best barometer.

I try to teach any newly diagnosed patients about what HD means for the rest of their lives, and also try to include the spouse/significant other. Teaching family can be tricky since families aren't supposed to be present during the treatment. I had always worked with family present at my former dialysis job and as a Peds ICU RN.

ON occasion, I will confess to forgetting to clamp the saline line. As for the stethoscope, it is on record that I am hard of hearing and must use my electronic stethoscope. For isolation patients, I put it in a clean garbage bag. I can hear nothing with those cheap things. If my hearing aids are out, a bomb could explode behind me and I wouldn't hear it, only feel the vibrations.