Taking care of patients with ESRD in medical-surgical areas of the hospital presents unique challenges both for the staff and the patients. With the nursing shortage, effects of the Balanced Budget Act, and increased acuity of patients, patients with ESRD are more likely to be housed on a general medical-surgical unit than on a dedicated renal unit. This usually means that the nurses and technicians receive minimal, if any, education on the specific needs and issues for this patient population.

Many medical-surgical units have a standing routine of passing out cups of water to all their patients at the beginning of each shift. This could spell disaster for patients with ESRD who are on fluid restriction. Often times, family come in and assume that because the cup of water is there, that the doctor must have ordered it. A compromise must be reached to keep from isolating these patients but being prudent with their care.

There is potential for error and for damaging vascular accesses when checking vital signs or drawing blood specimens. When nurses or technicians are not trained to recognize grafts and/or fistulas, blood specimens and blood pressures get taken from an arm with a vascular access. Medical-surgical staff need to know how to determine which vessels are thrombosed and which are still patent.

Pain Management and Procedures

One of the most common mistakes is that procedure areas do not make allowances in their standing orders or protocols for patients with ESRD . Frequently, we see Lactated Ringers IV solution ordered instead of a normal saline solution. This often occurs because all patients undergoing endoscopy (or other procedures) get Lactated Ringers solution, but the effects for patients with ESRD can be serious.

Pain Management is another common issue. Demerol may be ordered and given without question because it is commonly given with surgical patients. When patients with ESRD have surgery, surgical nurses aren't aware that Demerol is not appropriate for these patients.

Cardiac Arrest or Codes

When patients with ESRD experience cardiac or respiratory arrest in the hospital, clinicians often struggle with what access to use. If the patient has a dialysis catheter, someone who is unfamiliar with its dynamics may access it during a code. For example, failing to withdraw the heparin prior to pushing an amp of Epinephrine could be fatal.

Phosphate Binders

Phosphate binders are used extensively for patients with ESRD. However, when the nurse is not familiar with their designed purpose, the benefit can be negated. For example, many nursing units give phosphate binders at 9 a.m. Unfortunately, the breakfast trays come at 7 a.m. Consideration is often not given to changes in the patient scenario. What happens when the patient is NPO for a procedure? Are the binders held or given? When patients are on a clear liquid diet post-op, are the binders held or given? These treatments have nuances that must be given consideration to provide optimal outcomes.

Holding medicines

Often staff on medical-surgical areas are undecided as to whether to hold blood pressure medications the morning of hemodialysis. Parameters must be identified and standardized to provide guidelines for care.

Solutions