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Skipped Two Times

Luo, Shixiang MSN, RN

AJN, American Journal of Nursing: March 2013 - Volume 113 - Issue 3 - p 72
doi: 10.1097/01.NAJ.0000427891.41935.38

After a crisis, a dialysis nurse realizes her patients need more self-management education.

After a crisis, a dialysis nurse realizes her patients need more self-management education.

Shixiang Luo is a hemopurification nurse supervisor at Affiliated Zhong Shan Hospital of Dalian University, Dalian City, Liaoning Province, China. Contact author: Reflections is coordinated by Madeleine Mysko, MA, RN: Illustration by Neil Brennan.



A young man in his early 20s, whom I will call Xiao Liu, had been coming to our department three times a week for several years for renal replacement therapy to help him discharge excess water and metabolic waste from his body. He was still in high school when he'd been diagnosed with renal failure as a result of systemic lupus erythematosus, and he never stopped studying, reading and writing, even during his appointments.

“I'm preparing for the university entrance exam,” he often told me. He was upbeat and grateful, despite the disease. I admired him for his strength and spirit and felt terrible that he'd been diagnosed so young.

One day at 10 am, the beeper rang, summoning the crisis team to the emergency unit. I hustled to the adjoining patient care tower. Mary, the charge nurse, told me that Xiao Liu needed a fistula puncture for continuous venovenous hemodiafiltration. He'd skipped his routine dialysis two times over the past five days; there was too much water and waste in his body, leading to acute left ventricular failure.

At the first sight of him—in high Fowler's position, coughing blood, pale with facies dolorosa, with pink frothy sputum on the nose and mouth—I felt brokenhearted. Breathing with difficulty, he said he was going to die and asked me to help him.

I waited for him to calm down and breathe more slowly as I prepared to puncture the fistula. The vascular pulsation was hard to feel, the murmur at the fistula too weak—obviously, his circulation had worsened. The blood flow was insufficient for extracorporeal circulation; the equipment alarm rang over and over. In this condition, he couldn't continue hemodiafiltration therapy.

Xiao Liu became agitated, shouting “I can't do it, I can't do it” and coughing bloody sputum more heavily. He grasped my hand in desperation, groaning, begging me to help him. Tears filled my eyes—although I wanted to help, there was nothing I could do but calm him down and instruct him to take deep breaths.

The emergency ICU physician arrived and immediately initiated emergency cannulation of a deep vein of the lower limbs. He soon achieved temporary vascular access for therapy.

After five minutes of therapy, Xiao Liu gradually began to resume his normal state. “Father said I was guilty,” he told me. “I missed dialysis because I went to Beijing for a tour. This must be what I deserve. From now on, I'll never go anywhere else.”

He began to weep, and for a moment I hesitated. Then I asked him, “Do you think yourself guilty? What do you think causes bad consequences?” In answer, he told me he'd looked up information about lupus on the Internet and thought he was going to die. Since his childhood he'd cherished two dreams—going to the Great Wall of China and going to college. In going to see the Great Wall, he'd wanted to realize at least the first of these before he died. Now, though, what he most wanted was to feel forgiven by God and to find a way to forgive himself. He seemed nearly overwhelmed with fear and unrest.

I patted him on the shoulder and nodded in response, assuring him that he could still have a long life, even with lupus and the need for dialysis. I had to see other patients, and I didn't come back until he was out of danger.

It's hard to put into words how ravaged Xiao Liu looked from his condition, his expression of pain, the telltale desperation in his eyes, and the sound of his pleading cries. He touched the heart of everyone who was there.

At the same time, I felt remorse at our department's weakness in patient self-management education, and knew we should put greater emphasis on how to control interdialysis weight gain from excess fluid in the future and tell dialysis patients not to miss regular appointments without permission. Despite the fact that they urinate little or not at all, many dialysis patients eat or drink as much as they did when they had healthy kidneys. If they don't get excess water and harmful solutes out of their blood promptly by dialysis, they can build up fluid in their lungs, heart, and limbs, resulting in discomfort or even sudden death.

Crises like the one that happened to Xiao Liu will keep happening if we don't do more to change patients' ideas and help them understand the importance of a healthy lifestyle. I now understand that it's my obligation and responsibility to help them with this.

© 2013 Lippincott Williams & Wilkins, Inc.