Toileting during Dialysis

Double-Helix, BSN, RN · Aug 25, 2012

Patients on dialysis may rarely make urine, considering they are on dialysis because they are in kidney failure. So it's not unreasonable to expect that they won't have to pee in four hours.

You have to have some understanding of dialysis facilities. There is not ancillary staff like CNAs to assist with transferring patients. The nurses need to be on the floor to monitor their dialysis patients and often have multiple infusions at one time. Leaving the floor in order to take patients to the bathroom is not a realistic possibility. Depending on the type of facility, they may not even be equipped with a bathroom large enough to accommodate the patient, plus the staff needed to clean and transfer them.

It's not normally within the job of the dialysis nurse to toilet the patients who are there for dialysis treatments.

If you have incontinent patients who are going to dialysis, you should make sure that the staff are toileting them immediately before they leave. Place a brief on the patient if they may be incontinent while they are gone, and make sure they are toileted when they return.

Trauma Columnist · Aug 25, 2012

I always liken outpt dialysis like a doctors office. If a pt can do for themselves, they must do so. If the pt is unable to transfer by themselves, then it is the NH responsibility to send someone with them or come and change the pt at the dialysis unit.

Long Term Care Columnist / Guide · Aug 25, 2012

Working in LTC, I too have seen this happen time after time---diabetic dialysis patients coming home without having received their mealtime insulin, incontinent patients sitting in soiled briefs, patients with B/Ps in the 60/30 range. I know there are at least some dialysis centers that employ techs; why can they not change/toilet patients when necessary? Why aren't blood sugars checked and insulin given when chair time goes through lunch? And why are patients sent back while their blood pressures are still in the dumper?

As most everyone knows, staffing at LTCs is already terrible, and certainly doesn't allow for a CNA to accompany a resident to dialysis. Maybe if there were a good reason (NOT money) for why the care at dialysis centers seems non-existent, LTC nurses might be a little less upset when our residents who are on dialysis come home with FSBS of 40 or 400, and often reeking of stool that they've been sitting in for hours.

Double-Helix, BSN, RN · Aug 25, 2012

Working in LTC, I too have seen this happen time after time---diabetic dialysis patients coming home without having received their mealtime insulin, incontinent patients sitting in soiled briefs, patients with B/Ps in the 60/30 range. I know there are at least some dialysis centers that employ techs; why can they not change/toilet patients when necessary? Why aren't blood sugars checked and insulin given when chair time goes through lunch? And why are patients sent back while their blood pressures are still in the dumper?
Maybe if there were a reasonable explanation of why the care at dialysis centers seems non-existent, LTC nurses might be a little less upset when our residents who are on dialysis come home with FSBS of 40 or 400, and often reeking of stool that they've been sitting in for hours.

The simple reason is that they are there for dialysis. Nothing else. The nurses don't have orders from the MD to check blood sugar or administer insulin. Nor do they likely keep insulin at the dialysis facility. They are at the dialysis center for a specific purpose- dialysis. Like I said above, it's often not possible for the staff to leave the dialysis center/floor to transfer patients and in some cases the policy at their facility does not allow them to transfer patients. If the patient were to be injured or fall during transfer the facility would be liable. Or the nurse/tech were to be injured while transferring, their workman's comp would not cover it.

Lynx25, LPN · Aug 25, 2012

I always liken outpt dialysis like a doctors office. If a pt can do for themselves, they must do so. If the pt is unable to transfer by themselves, then it is the NH responsibility to send someone with them or come and change the pt at the dialysis unit.

I have 30 patients, the aides have 15, and this hall has three different people going to dialysis. Who am I supposed to send with them?

I calculated my time out one day a few weeks ago. I'm allowed about 20 minutes per resident, per shift- to include four med passes, charting, drawing my own labs (and some days, driving my own labs to the hospital) doing my own treatments. I still make time to toilet people when they need it. We do change them, making it a point to change some people AS the EMTs are walking in to get them, just so they can try and make it through the treatment.

You'd think that this facility that accepts dialysis patients from all of the surrounding LTCs would have come up with something better than: "Let them sit in it" as a solution.

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Double-Helix, BSN, RN · Aug 25, 2012

You'd think that this facility that accepts dialysis patients from all of the surrounding LTCs would have come up with something better than: "Let them sit in it" as a solution.

You would hope so, but think of it this way- How likely is it that YOUR facility will pay extra aides so that you can send someone to dialysis with the patient? Well, when the solution involves increased staff/expense on the part of the dialysis facility, it's about just as likely that they will foot the bill.

By the way, when I worked as a CNA in LTC, and a resident had to go to an appointment where the facility had to transport them, they also had to send a CNA with the patient for the appointments. Yes, it left the rest of the floor short-handed, but there wasn't anything we could do about it.

MJB2010 · Aug 26, 2012

As a former dialysis nurse, I can tell you this. Our medical director doesn't care how much time you have at ltc per patient, nor will they foot the bill for supplies. I was the only nurse in the building, and could not leave the floor to pee myself, never mind assit a patient that requires a lot of assistance to the restroom. We barely had enough staff to keep the patients dialysis going. Patients are constantly coming off and on the machines and their vitals and condition are rounded on constantly. We didn't have wipes, we did not have briefs, we did not have a change of clothes to change the patient into. We don't keep insulin or pain medicine in the dialysis center. We were bare bones, an OUTPATIENT clinic. We did however, take patients off of the treatment, which required rinsing the, back and giving them a lot of extra fluid, if they had to use the restroom and were able to. Dialysis patients can bleed out in under 3 minutes if a needle slips. They can code at the drop of a hat. All staff needs to be watching the patients for their entire treatment. We don't have extra staff to cover the ltcs lack of staffing. You can't send a can, so who is supposed to make up for that?

I can tell you it was a regular occurrence for our patients to come sitting in their own mess from ltc for thei treatment, can't you toilet them before you send me out? Maybe feed them if you know they will be gone for 4 hours? They were often given meds they were not supposed to have prior to dialysis making their bp unsustainable for treatment. Every time i called i ogt a different nurse, never the same one twice. It got to the point where I would call ahead 3 times a week to ask the ltc to please feed and toilet before sending the patient and reviewing all the meds to hold because they could never get it right. If you think dialysis is so easy and we are all just lazy kicking back, I suggest you give it a try. Maybe ask to shadow a day or so. If you understood what was going on. during the dialysis treatment you might have a better idea of why the patient can't be taken off cleaned and bathed any old time. It goes both ways and bth sides need to work together.

Just Like you say Money isn't a good reason, right back at the ltc and lack of staffing. We are all fighting the same battle here, let's work together instead of blaming the other.

Long Term Care Columnist / Guide · Aug 26, 2012

You know, it just struck me that we're all complaining about the same thing---LACK OF STAFFING!! And why is that? Because every area of nursing is understaffed. And why is that?

You guessed it. MONEY. It's all about the Benjamins, not patient care, and certainly not nurses' ability to do their jobs with adequate supplies, staff, and time. We've got to know healthcare is in ruins when we can park somebody in a dialysis chair for 4 or 5 hours and let them sit in their own waste because there aren't sufficient staff members available to toilet them.

What a cluster-mug. It's stuff like this that turns nurses against each other. How much longer are we going to take it without fighting back?

MJB2010 · Aug 26, 2012

The lack of staffing is why I left dialysis. I miss the patients a lot. But the days kept getting longer, the patient load got unsafe, and the medicaire reimbursements got smaller. So where does the money et cut? Staffing.

DidiRN · Aug 26, 2012

When I did chronics, and I worked in more than one unit, it was not unusual to put people on the bedpan or urinal while on dialysis. Not very many needed this because most were anuric and if it was a BM, most would just wait until they got off dialysis, they didn't want to go on a bedpan. On rare occasion we disconnected the ones who could walk to the bathroom but this was highly discouraged for infection control reasons and if they had needles in it wasn't very safe to leave them in, even taped up, when they went to the bathroom (keep in mind these are large bore needles (14 to 15Fr) in very large fistulas or grafts, they will bleed out very quickly). We also cleaned up incontinent patients, but because of the extreme fast pace of this environment, it was not done or checked like it should. I have never seen a staff member come from a LTC just to change a patient; never ever crossed my mind to do consider that. A chronic dialysis unit is like assembly line...get 'em in, run 'em, and get 'em out, unfortunately. Plus the staffing is always short almost everywhere I worked.

I was able to monitor blood sugars but there was no insulin there, we were not allowed to do any kind of coverage whatsoever. I did have meds to treat hypoglycemia but most units had to food or juice at all for patients. The medications I gave were the typical dialysis meds (epogen, iron, etc) and the only prns we had were Tylenol and sometimes antihypertensive and nausea meds. As for low BPs, that shouldn't be happening, sounds like they need an adjustment to their goal weight.

just keep swimming · Aug 26, 2012

I, for one, do not accept PCTs refusing to toilet pts. It is not reasonable for me to be off the floor that long when I have many other pts on the machine; however, I do not mind covering the PCT for the 10-15 min they are off the floor.

Is it our job to toilet? I'm told it's not, but I would be pretty angry if my mom or dad was left to sit in their own filth for 4 hrs. The one thing that I would ask of LTC nurses is to please make sure you send an extra brief with so that if there is an accident, we have something to change them into. The other thing would be a change of pants.

As for wipes, the ones we use to wash the chairs and machines with work great with some warm water.

I do agree with the other dialysis nurses about things like medications or insulin. If your pt has an appt at some other clinic at noon, wouldn't you feed them and give meds such as insulin either earlier or later?

If pts are coming back with low pressures, this needs to be reported to the dialysis nurse as there are things we can do to help this.