Seeking advice regarding Ultrafiltration rates

[Foleynurse2008]

Hello All,

I am an RN of 4 years, although a new Dialysis RN (7 months now!). I currently work in chronics, in a busy, outpatient unit with 27 chairs for 2 RNs. I work in an area that has a lot of non-compliance (i.e.-very large fluid gains, missing treatments, not going to appointments, etc.), thus, determining ultrafiltration can be difficult at times since it is not always possible to achieve a patients EDW and keep them safe.

I had a pt yesterday that came in with a gain of 3.8kg. However, the pt was 6.7kg over dry weight. The pt is known for having large gains. When rounding, I noted the UFG of 4.6kg (we add 0.6 for rinseback), and asked if I could decrease it. The pt stated that they wanted to try to get the fluid off (the pt is not small nor very large), and requested that goal. I said that they may experience cramping or problems with a goal that large, however, they still insisted that they could tolerate it and requested that I put the 4.6kg as the ultrafiltration goal. I even looked back to prior treatments and noted that this was not an usually large UFG for the pt, as they had previously taken off between 3.8-5.0kg's per treatment.

The treatment went well with the exception of a bout of hypotension during treatment (BP was in the low 100's), that resolved quickly (I was unaware of this as the tech did not inform me). The pts blood pressure was stable post treatment (120's SBP), and denied any complaints post treatment. They even spent a while talking to other employees after the treatment was over.

The pt. called the unit yesterday stating that they had a seizure on the way home after treatment (pt. was not driving, takes transportation) and we "took too much fluid off". The pt said they were fine and that they did not want to go to the ER. I strongly encouraged the pt. to go to the ER which they continued to refuse. I later had a family member of the pt. calling, very upset about the seizure, insisting that we removed too much fluid. It was very stressful.

Needless to say, I am seeking clarification on how we are to determine proper fluid removal during treatment. I am finding this stressful, as I really do care for my patients. I have experience in ICU nursing and have always been told I am a very good and thorough nurse. Despite this, I am finding myself struggling with some of the stress associated with the clientele and work environment at times that it does not even compare to my previous experience. In combination with some other challenges at my job, my confidence is really starting to go down.

However, with the large fluid gains and the patients being very resistant at times when you try to decrease their goal, what can I as the nurse do? Are there any suggestions anyone has for preventing this sort of problem in the future? The doctors are aware of the pts tendency to have large fluid gains and have had numerous discussions with them about it.

Any input would be greatly appreciated as I am feeling pretty bad :-(

Thank you!

[just keep swimming]

I work in a similar unit to yours and it can be very frustrating. First of all, make sure you document! Secondly, reevaluate the EDW. Does it need to be changed, does the patient show signs of fluid overload? With BPs like that, the pt may be dry already even if they are not at their EDW. As for how much to pull, it is important to assess the patient including past treatments just like you did. It is also important to determine how much the patient can safely pull according to their EDW. The newest guidelines state that we should remove no more than 15ml/kg/hr. This is another way to determine what is safe. Another option is to offer the patient an extra treatment, with a physician order of course, to remove fluid; that way they aren't pulling so much in one treatment. If they refuse an extra treatment, ask the MD if it would be okay to extend that days treatment by an hour (if your schedule permits) to remove extra fluid in sequential ultrafiltration.

Start using visual aids to teach patients. For fluid gains use a balloon that has never been blown up and compare it to a balloon that has been blown up and deflated. Tell them this is what happens to their heart after being blown up with fluid so many times. We also have different visual aids sitting around the clinic like a gallon jug labeled "if you gained 3.9kg, you drank this much". It prompts patients to ask questions. Having them hold the same number of saline bags as the number of kg they gained also helps get the point across.

As for how you are feeling, take it from someone who has been in dialysis for a very long time, you need to let some of that go. Patients are going to do what they want until they have their own ah-ha moment. Continue to teach them and care about them and one day it will click....or it won't, but at least you know you did your best.

I had a patient once who was obviously bacteremic. I spent an hour at his chairside trying to get him to go to the ER or at least wait until the antibiotics finished infusing. He left after half a dose of antibiotics and went home and collapsed and died in front of his kids. I was so torn up over this for a very long time, but in the back of my mind, I knew I did the best I could. That is all we can do. Hang in there! It's a tough population to work with!

[madwife2002, BSN, RN]

No more than 5% of dry weight should be removed

[Foleynurse2008]

Just keep swimming & madwife 2002,

Thank you for the replies! I agree with the need to reevaluate dry weights. Many of my patients need this done and it is an issue that has been addressed several times with the doctors. Some progress has been made, but not as much as we'd like.

The patient did not complain of SOB nor any apparent edema, but stated they can tell when not enough fluid is remove. The pt also has been known to down a 2 liter bottle of soda in one sitting despite constant education

Thank you for the suggestion, I really like the new guidelines and was looking for some sort of objective way to measure ultrafiltration rates so that is really helpful!!

The problem is getting the patients to stay in general. Many of them sign off early despite constant education on its dangers. The pt is compliant in that they usually come to treatment. However, getting an extra treatment in can prove difficult as we are usually booked solid. Adding time to tx also sounds like a good idea, and I think this is something I can address with the doctor, thank you! Showing the patient the saline bags sounds like a more effective approach than the typical lecture, I will try that next time!

The culture of my unit is something I'm not used to as we tend to not be overly aggressive with the pts since situations like missing treatments, signing off early, non-compliance, missing appointments, etc are literally an every day occurrence. This kind of drives me mad since I prefer to have all my ducks in a row (well as in a row as they get in nursing!) and its extremely difficult to know where my responsibility as a nurse stops and where they must pick up. I then become unsure of what to report to the MD and what not to.

I understand I cannot remove the drinks from their hands or stop them from eating those high phosphorus foods (I really try to educate). It then becomes frustrating cause then I must deal with K's of 8.0, patients missing over 7 treatments, and patients not showing up for access appointments 2 ,3, 4 times, even when we set up a ride...

I know I still have a lot to learn. I suppose the control freak part of me is spiraling from some of the craziness. I agree that the patient population in general can be difficult. Sometimes it feels like i'm chasing problems all day long. I did hospital nursing for four years and did not find it nearly as frustrating.

Oh my, that is the kind of scenario that is difficult to shake for a nurse. We all have our unforgettable moments. Things like that can be really hard to get over, but you did everything you could do and then some. You are right though, the patients will do what they want, and we can only advise them as necessary.

Thank you for the advice again, I really appreciate it!

[FransBevy]

Unfortunately many of the poor lifestyle choices that led to ESRD (ie: high A1c's, poorly controlled hypertension, unhealthy diet and exercise routines, etc...) aren't often changed once the patient has reached the dialysis stage. I'm about 5 kg overweight and have hypertension yet I still couldn't resist a bag of chips with my grilled cheese sandwich at lunch. When I remember that it reduces my level of frustration with my patients. :)

Really, I could never do as well as most of them, I swear!

[madwife2002, BSN, RN]

I agree FransBevy

[madwife2002, BSN, RN]

To the OP please never lose your enthusiasm or drive, it is what our patients need. Sometimes our job is thankless but we must never stop trying to educate and improve their outcomes.

[schnookimz]

Are they a trustworthy patient? I mean are you sure he probably had a seizure? They aren't over dramatic or anything?

I just figured that if they were getting transported then the driver for sure should have called 911!

[Foleynurse2008]

I can absolutely understand that. And much of the non-compliance makes sense given the fact that the patients are ESRD. I can even relate to that on some level. I can understand not wanting to comply all the time, it must be exhausting sometimes!

[Foleynurse2008]

Schookimz & Admin.

Well, therein lies the question. Many of our patients tend to fabricate, well, a lot. The doctors have had a lot of issues with that. I even tend to be too trust worthy at times, but even with that tendency, sometimes the lies are too obvious. Patients will say things like "I went to go to my appt. yesterday to get my vein mapping done but they sent me home cause I had a 103 fever!". Then the patients afebrile, WBC count is fine, no signs of infection present, and when you inquire with the office, the doctors, etc, the patient never even showed up and declined transportation when they came to get them for the third time...

I tried to question the patient about what exactly happened and they said they "just fell out of it" and woke up on the floor of the bus. My patients are very dramatic actually, its part of the culture present there. I've had patients yell and curse at me because they didn't like the way I stuck them, and many of our patients are verbally aggressive with the staff and one another (there's a lot of younger males, so they sort of compete with one another in a battle of puffing the chest).

I asked the patient why they, or the driver didn't call 911 when they seized, and their response was that they "felt fine after, so they refused it. Which I find interesting since most seizures have a post-itcal phase that renders people incoherent for a while. I then asked if they had a history of seizures, to which they said "No i don't...but I used to get them every time i smoked weed" SIGH.

Needless to say, its exhausting at times.

I agree that our jobs can be very thankless. I will say, one positive thing about dealing with the patient population I've been working with is that they do not trust easily. So to see glimpses of trust from time to time with some of them does feel good and helps me remain enthusiastic I agree that we need to try to keep that feeling though, it is truly important in the spirit of nursing...

Thank you everyone for your input!

[Chisca, RN]

Any UF removal more than 7-10cc per kg/hr is associated with hypotension and poor mortality. The problem is if that criteria is adhered to treatment times have to be increased or an extra treatment is needed. And what patient is agreeable to that? I don't know if your patient really had a seizure or more probably still hadn't equlibrated from the large UF removed from his body. Ask the patient to remember how they felt and do they want to continue to feel that way because something is not right if you are trying to remove 4-5 liters between treatments. What does the patient think the issue is? Why are they so far off their dry weight?

[ausrnurse]

We used the "no more than 1L per hour" approach at my unit, and frequently used UF profiles to try and prevent hypotension. You also eventually learn what patients can and cannot handle. Make sure you document everything (including that your UF goal was at the patients request - they do have the right to request to a certain point).

In regards to non-compliance, well, you just have to accept it and try not to let it stress you out - easy to say, I know, it's why I left chronic HD. All you can do is educate and perform your legal responsibilities.