Lisa Maxwell

Congratulations to Lisa Maxwell, CHN, a recipient of the 2008 Wesley Watkins Scholarship Award

“Managing the Difficult Dialysis Patient”

When managing the difficult dialysis patient, what first comes to mind is the “non-compliant” patient. This is the patient that neglects his fluid restriction orders and frequently misses his dialysis appointments. He may arrive three hours after his scheduled appointment and be seven kilograms higher than his target weight. As an RN working with dialysis outpatients and inpatients, I review, for what seems like the hundredth time, his fluid restrictions and the importance of adhering to his dialysis schedule. He responds as if he is hearing all this for the first time. Another dialysis patient arrives, carrying with her a 64 oz cup of soda and a bag of chips. I explain the possible complications of increased fluid intake and a diet high in sodium or phosphorous. She says she will eat whatever she wants.

It’s easy to become frustrated and start to think that many patients are simply not concerned about themselves and will not follow recommended diets, fluid restrictions or treatment adherence. This is simply not true. Patients do care. They do not want to be sick. When they don’t follow medical advice, it may be they are unwilling to accept their diagnosis, or feeling depressed, or simply need to feel in control. When they miss appointments, it’s often because they have a difficult time getting reliable transportation to dialysis and on some days they may not feel well enough to leave their home.

cannulate a tiny fistula can seem overwhelming. Another patient may always cramp, or have anxiety attacks, or restless leg syndrome. Coping with such issues, singly or in combination, can be difficult for the nurse and painful for the patient.

The most effective ways to manage both types of patients are the same. Support them continually through encouragement and education. When discussing their dietary restrictions or the limits dialysis may put on their activities — don’t just focus on what they can’t eat or do, talk about what they can. Involve the patient as much as possible, which can reduce their anxiety and help them feel more in control. When a patient doesn’t follow medical advice, try to understand the reason for their lapse, rather than reprimanding them for it. If their dialysis is complicated by other issues, guide patients to the appropriate resources for medications or access care. Finally, while patients are ultimately responsible for the choices they make, we are responsible for providing them the best care possible and that’s easiest done by accepting and respecting patients for who they are.

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