Elizabeth Blair Archibald

Fresenius Dialysis Clinic

Coos Bay, Oregon

My day at the dialysis clinic was extremely interesting. When I first walked in I had no idea that
I would walk into a very large room with 60 (+/-) dialysis chairs all filled with patients, hooked
up to machines, and watching television or listening to music to pass the time. I pictured a
scenario like the infusion clinic in Brookings.

At this site, the patients are scheduled for Mon/Wed/Fri, or Tues/Thurs/Sat.

When I first arrived, the clinic manager, Melanie, showed me around the building. In the back,
the dialysate is mixed. There are giant tanks full of (1) acetate (potassium/calcium), and (2)
bicarbonate. The techs are responsible for managing the machinery that produces the dialysate
solution.

After this, Melanie paired me up with Omna the dialysis technician. Omna was amazing! She
was fast, smart, and compassionate. She really knows her stuff! She is so good, that for the first
hour, I thought SHE was the registered nurse.

Omna was responsible for prepping the machine for the patient with the NS fluids, lines,
prescribed dialysate, checking the dialysate PH and conductivity, checking the patient in,
getting their wet weight, having them wash their access device, getting patients standing
BP/then sitting BP, instilling dermal lidocaine around access device if needed, cannulation,
instilling heparin to dwell for 5 minutes (heparin is also in the lines/dialyzer), giving a bolus of
300 ML NS, and finally setting the dialysis rate, calculating end dry weight, **determining with
RN the ultra-filtration rate needed to reach end dry weight (determined per patient, and what
they can tolerate), and starting the dialysis. While patient is receiving the dialysis, the
technician is responsible for monitoring the venous and arterial pressures (must be a half of
what the rate is- EX: rate of 450, pressure must be 225 or lower), taking blood pressures every
30 minutes (or Q15 mins if indicated), documenting BP, and making sure that the patient
doesnt have any adverse reactions. The tech discontinues the heparin in the dialyzer one hour
before they leave. When the dialysis is completed, Omna unhooks the patient, takes a sitting
and standing BP, disposes of the biohazardous material, and sanitizes with bleach. Pressure
must be held at site of cannulation for at least 5 minutes.

**Omna was an excellent patient advocate. The RN wanted the patient to dialyze 2.6 (I dont
remember the units liters?) of fluid, but Omna has known the patient for years. She knew
that he could not tolerate losing more that 2.0, and spoke her concerns privately with the
RN.**

Rob was the RN that I worked with. His responsibilities are less task focused, and more thinking
focused. Omna runs circles around everyone and is always moving, and the RNs are more in
deep thought. Robs responsibilities, include: Assessments (heart, lungs, edema, skin
integrity), evaluation, making sure that access site is patent (thrill and bruit) and not
red/swollen/painful, making sure that patient hasnt had any life changes or concerns,
determining the ultra-filtration rate needed to reach end dry weight (determined per patient,
and what they can tolerate), if patient has had any recent falls or bleeding (heparin), care
planning***, interventions if EDW is too low**** , foot checks once a month for sores, go over
meds once a month, and administer vaccinations.

*** Care planning: Done on first visit, then in 90 days, then yearly. If the patient is unstable,
the care planning will be done monthly until stable.
**** Signs and symptoms of EDW being too low: cramps, hypotension, nausea, vomiting. If
this occurs, they will give extra NS IVF.

The clinic does not have a physician on site. They have standing orders, and algorithms to
follow. A physicians assistant comes Monday and Tuesday to see all patients, and a teledoctor
from Eugene is available if needed.

Meds: The tech can give lidocaine, and heparin.

The nurse can give oral: Clonidine, Benedryl, Antacids, Tylenol, Nitroglycerin, and Kayexelate;
and intravenous: Heparin, Vitamin D, Epogen, Iron, Ondansetron, Calcium Gluconate, Sodium
Thiosulfate (treats calcium bumps in the soft tissue), antibiotics, Sodium Citrate (allergic to
heparin), and Dextrose.

If the patient has Albumin less than 4, they get a protein shake before the treatment, or a
protein juice shot that contains 16 G of protein in 1 tablespoon.

Labs are rechecked once per month, and the dialyzer monitors Kt/V (determines if dialysis was
effective) on site.

Time: 1100
Data: Patient needed to leave clinic early/discontinue his treatment early because his ride
needed to pick him up at a certain time.
Action: Student nurse contacted many organizations to see if there was a transport service
available for situations like this one, without a positive result. With patients permission,
student nurse called patients ride to see if she could come later.
Response: Friend that was serving as patients ride agreed to come later so that patient could
have a complete dialysis treatment.
Signature: Liz, student RN