Hospital Triage System
A typical afternoon shift of a nephrology nurse in an acute or hospital setting starts by clocking in at 2:00pm. Due to the COVID-19 pandemic, before we could enter the hospital, we need to undergo triage and have our temperature checked first and our wrists stamped. Strict measures are being mandated through one way pass therefore we couldn’t do shortcuts even though our time-in device is located nearby the exit door.
Entering the hemodialysis unit, we cater both acute and chronic kidney diseases (both outpatient and inpatient) having a total of 3 shifts for patients while 2 shifts only for nurses–6 to 2pm and 2 to 10pm shift. So, 2nd shift patients will be endorsed between the morning and afternoon shift nurses. What we usually do first once in the unit is to check the patient assignments, shift assignments and to whom we’ll get the endorsement. The nurse-patient ratio is either 1:2 or 1:3. Then, we’ll change to our overall suits.
The Nephrology Nurse Team
The afternoon nephrology nurse team consists of 5 to 6 nurses. One nurse will act as the team leader who is also in charge of doing the administrative tasks such as charging patients, admitting patients, logbook and paperworks. In other words, the team leader takes the biggest responsibility of the shift. Thus, this role isn’t just given to anyone else but to the officer in charge or head nurse, senior staffs or junior staffs if OIC or seniors are not around.
As soon as the nurse to nurse endorsements are done, TL to TL is next. This is termed as the “midconference” where the morning and afternoon shift nurses are all gathered at the nurse station to listen of new endorsements, announcements or memorandums. Ofcourse, a shift can’t start without saying the nurse’s prayer.
Patient and Task Monitoring
Afterwards, everyone are dispersed to their respective areas nearby their patients assigned. The team leader does his or her administrative tasks, most nurses start monitoring their patients, do charting and some initiates their shift assignments. As the officer in charge of the unit, when staffing ratio is enough, I don’t take the team leader role neither handle a patient so I could focus with DOH or ISO paperwork.
Transition: End of 2nd shift dialysis patients sessions
The first sound of the machine signifies the start of transition around 4 to 5pm meaning one of the 2nd shift patients have already finished their session. The 3:00pm technician will be the one who will assist the nurses in returning the blood to patients, discard the bloodlines and reprocess the dialyzers. The 10:00am nurse technician on the other hand, primes the machine and hook the dialyzers right after. For nurses who are assigned to patients with the same end time can exchange with other nurses.
To those assigned to inpatients, they need to endorse the patient in stable condition back to their original station. For the outpatients, nurses take post hemodialysis vital signs and weight and give post medications if there are any and discharge them in stable condition. Patients who experience post HD complications such as high blood pressure, their respective attending physicians will be called for any new orders and the nurses will then carry out. Once patients stabilize they are good to go. In cases they don’t stabilize, most likely they are advised for admission and this is where the bloody job happens collaborating with the residence on duties, emergency department nurses, medical technicians, radiologists and inputting everything in the computer system and of course taking care of the patient for admission is the top priority. In short, the nephrology nurse more likely acts a telemarketer.
Transition: Start of 3rd shift dialysis patients sessions
3rd shift starts simultaneously with the end of 2nd shift patients’ sessions. We have a total of 10 Bbraun dialog machines, therefore it takes speed to start patients while others are still decannulating or closing catheters. Bbraun dialog machines take a couple of minutes to be ready so we usually dress catheters or cannulate patients first then we move to the next patient.
Thus, we have a rule that to anyone who will cannulate the patients or dress the IJ or PC will be responsible for getting the pre HD weight, vital signs, assessments, calculating UF and setting the machine and preparing the heparin syringe pump. Because once the machine is ready to be hooked to patient, the nurse who dressed or cannulated is not guaranteed to be available at the moment. So, anyone who is available can easily hook the patients to the machine without the need to do the pre dialysis stuff rather just double checking the chart. Any incident that will arise during these stage, the nurse who dressed or cannulated is accountable and the nurse who hooked the patient receives a warning. For the inpatients, endorsements from the station will be taken earlier before transition and will just be called to be transported once machine is ready.
First Time AVF Cannulation
The seniors will be the one who will cannulate fresh AVFs for straight 8 sessions to avoid causing trauma or further damage on the new site. The junior can start cannulating on the 9th session while the probationary nephrology nurses on the 12th session with assistance of the seniors or juniors.
As of this writing, I was the only senior during my previous shift and there were around 3 patients who have fresh AVFs. 1 inpatient admitted for initiation of dialysis with no CVC in place and 2 regular outpatients who both have sensitive veins while the other had her second AVF creation. We have a rule that for fresh AVFs, we do not recannulate but revert immediately to CVC. Also, we start with one site first either arterial or venous then the other will be via CVC. However, in the case with no CVC in place, I had no choice but to cannulate both sites. I started with the inpatient cannulating the venous site first which unfortunately, bombed immediately with the use of the torniquet. I decannulated, applied cold compress and let it rest and I proceeded to the next patient. The first outpatient I cannulated was successful but the second one was not. I went back to the inpatient, the swell have subsided. Another rule for first time AVFs is to cannulate both in an upward direction but since the upper area has been compromised, I had to cannulate the arterial in a downward direction. This time, I did not use a torniquet and I finished both successfully. The arms of the patient is a bit chubby so the use of torniquet must have compressed the fats above the vein compromising my cannulation.
Believe it or not, I had my sweats dripping all over inside my red overall suit and with the helmet on. I sat as if I’ve carried tons of heavy packages. Little did I know, it was already dinnertime. However, before that, we check first our patient assignments for 3rd shift.
Being a Nephrology Nurse
That’s probably the same procedures we do every shift. We call the patient, we weigh them. We place them comfortably to their assigned chairs or beds, we get pre hd vs and assessments, gather materials then cannulate then vs again. Set the machine, chart and relay to the attending physician.
Although, it’s a routine but to be honest it’s still something that I don’t get tired or bored easily. I don’t know why but if the department that you are currently working in is what really interests you then, I guess it’s not something you consider as a job but rather a hobby or your passion. Everyday is a learning process and you get to experience that with a bunch of lovely and friendly nephrology nurses.
This is something that I’ve held on for the past four years (read here the day I got in as a nephrology nurse) and to say being a nephrology nurse is boring is an understatement. Each day is as reenergizing as it is tiring. What do you think?