When training with stepladder method can someone explain what the patient should feel as the needle advances in order to know if he is placing the needle properly? How does one manage taping the needles down one handed? Do you use wet or dry method? Would appreciate any tips you can share.
Is there any particular reason you are using stepladder and not buttonhole technique?
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We must learn both methods.
Have you asked your nurse why it is important to learn both methods? If you have successful buttonholes, you’d never need to do the stepladder method.
Will start the tunnels with sharps and if a tunnel ever closes up, must know how to stick with a sharp. And if there was ever a problem might need to stick with a sharp elsewhere for a tx.
Just like with dulls, you should feel it go in the vein. Don’t go too fast and you will see the blood come back into the needle, you know you are in so you straighten out.
I see no reason to do a stepladder method. Even if your buttonhole closes up, you restick the same place with a sharp to open it up. Yes, you need to know how to stick with a sharp, but no need to stepladder your sticks, stick the same place over and over until the buttonhole is established (assuming you have a fistula). There really isn’t any difference in how you stick between the two methods, just with the buttonhole eventually you switch to a dull needle.
If your tapes are pre-pulled the needle pretty much stays in place and you simply put the pre-pulled tape on the needle. Awkward at first and now, so simple, I even fold my guazes with one hand.
Cathy
self home hemo 9/04
My program also teaches cannulating with sharps first, and then buttonholes. If some unlikely scenario should occur that requires cannulating elsewhere than an existing buttonhole, but at the same time, does not require going into centre for it, we can use a sharp because we have been taught how, and then, you’re only 6 days from having established a new buttonhole if need be. We are taught the go in at 20-25% and then level off technique. Obviously, you have to do it in a way that the needle will be well into the vein, and that you won’t go through the other side of the vein (but that happens even to experienced dialysis nurses in centre occasionally).
I don’t know if I agree with the two sets of buttonholes idea. It seems to me that this would create four opportunities for eventual aneurysm instead of two, and that this defeats the purpose of using buttonholes in the first place, as far as prolonging fistula life goes.
Pierre
By the way,
I guess this might vary depending on the fistula, but…
If you can’t get the dull needle into a buttonhole, chances are you’re just very slightly off. But it does happen, and then you must use a sharp – you cannulate it into the buttonhole using the exact same technique as you would with the dull needle. With my own setup, with a buttonhole needle, I go straight in, and so, if ever I need to use a sharp in it, I use that technique.
If I should have to cannulate with a sharp in a different spot (ie. other than a buttonhole), I would use the go in at 20-25 degrees and level off technique.
Pierre
Those of you who buttonhole, how often have you found that you have to use a sharp on your buttonhole?
The first couple of months, maybe once every couple of weeks. Then it drops off to almost not at all, as long as you are very careful with your buttonholes. You must make sure that you have either taken the scab off, or if there is no real scab (as often happens to me), that you have slightly punctured the spot where the needle should go in – otherwise, you gradually deflect away from the buttonhole tunnel a little as you force the needle in, this causes scar tissue to form, and before you know it, some night, the dull needle just won’t go in.
But for sure, the first 2-3 months, there’s more chance of having to use a sharp every once in a while. For me, when that happened, the dull needle would go through just fine until it hit the vein, and then there was no way it was going through the vein wall.
Pierre
[Cathy writes:
quote]Just like with dulls, you should feel it go in the vein[/quote]
Do you mean patient will feel the needle puncture the vein-the “pop”? Should one always feel the pop?
Cathy writes:
If your tapes are pre-pulled the needle pretty much stays in place and you simply put the pre-pulled tape on the needle. Awkward at first and now, so simple, I even fold my guazes with one hand
Can someone explain how you tape needles as we have seen different styles. I am referring to regular cannulation at this time as we are not on buttonholes yet. At first while learning is it best to use wet sticks since one may fumble expending time?
Pierre writes:
you have to do it in a way that the needle will be well into the vein, and that you won’t go through the other side of the vein (but that happens even to experienced dialysis nurses in centre occasionally).
Does a self-cannulator have more control over this then a nurse such that one would feel when the wall is hit and stop in time?
Pierre writes:
I don’t know if I agree with the two sets of buttonholes idea. It seems to me that this would create four opportunities for eventual aneurysm instead of two, and that this defeats the purpose of using buttonholes in the first place, as far as prolonging fistula life goes.
This seems to make sense.
Do you mean patient will feel the needle puncture the vein-the “pop”? Should one always feel the pop?
I don’t think so. I don’t feel any pop at all. You can’t count on that.
Does a self-cannulator have more control over ((infiltration due to poor cannulation)) then a nurse such that one would feel when the wall is hit and stop in time?
Maybe a little, but not really that much more. When you are using the stepladder pattern of cannulating with sharps, there’s always a chance that you will cause infiltration, unless you have a very mature fistula so large that you can’t miss. Infiltration often doesn’t happen right away. Sometimes, the needle tip is just touching the vein wall, and after a little while, or after moving your arm, it pokes through. In addition to possibly prolonging the life of your fistula, this is why home hemo patients are taught to use buttonholes. They are incredibly more predictable than when using sharps.
Pierre
In learning to self-cannulate, it is comfortable to stick both venous and arterial going up, but harder to get in there to stick arterial going down on upper arm access. What have others experienced?
When the initial sticks are made for the buttonhole what angle is being used?
Did anyone have written material for self-cannulation (both types) when you went through training for your home program? Or how about video training? We have a video on cannulation, but it does not deal with self-cannulation showing how a self-sticker would hold the needles, tape one- handed and so on.
Not for me, just the nurse to show me. The trick for me when inserting at another angle is the reverse the needle in my hand, ie pointing towards my hand vs. away from my hand, that way my wrist is in the same position and it is comfortable to insert the needle. Now I keep my needles pointing the same direction (with the flow of blood), but go at an odd angle with one buttonhole due to a kink in my fistula.
Hope this makes sense.
Cathy
Here’s a list of tools, some for patients and others for professionals that are from Medicare’s Fistula First project. In among printed materials, the list includes some videos that your clinic might want to order.
I have been self-cannulating since Sept of 2004; I began the buttonhole techniqure last June 2005. I have several times though they are less that I have difficulty finding the tract. A couple of times I have asked a trained PCT to Complete the stick. I have yet to try to open up track with a sharp. I do not believe that is necessary. Once I locate the track it allways, repeat allways slides in easily. I do wish to learn more about the best way to stick. The comment by one poster that not removing the scab completely could deflect the needle sounds plausible. I know one of my main problems is “light” and eyesight. I have no plans to open with sharp until someone convinces me that that is the wise way to complete a difficult stick.
I am presently developling a secondary pair of buttonhole sites; one RN suggested that even if not using a buttonhole site that it will not close up; any comments?
Thanks for any replies…
Charles :roll:
I personally don’t see the need for a second set of buttonholes. What are they for exactly? The whole idea of buttonholes is to preserve the fistula as long as possible by avoiding extra needle sticks (this is what renders a fistula unusable after a few years). Buttonholes don’t fail, fistulas fail. If you need a new buttonhole at some point, it’s not a big deal to start a new one. You’re always only six days from a new buttonhole. And yes, they definitely do close up after a while. If you have two sets, you would probably have to alternate from one to the other. Better to save the location of that second set of buttonholes for future use.
Pierre
I am a home patient who recently started with buttonhole after being on hemo/home since Dec 03. Starting the track with sharps was not bad. Arterial was more difficult. Since starting with dull needles, a lot of trouble. First getting the scabs off is very hard ( my fistula is on my upper arm). Next the pressures areall over the place. When I was preparing, pressures were good and consistent each day. I do treaatment 6 days per week. This message board has been the most informative thing I have ever seen. I have used a sharp since starting with the blunt because my husband couldn’t get thru.Has anyone had the issue of skyrocketing pressures?
You bet!
Took me quite a while to work out how to get the pressures right. I know everyone is different and I was doing the same things (I thought ) that I was doing with the sharps but it seemed that the way I got the pressures right with my buttonholes was to level off a bit earlier and flip my arterial. I have now had 3 whole weeks of perfect pressures and no alarms during 8 hour runs. I can get the buttonhole cannulas in (every second night) by gently twisting back and forth which seems to loosen up the tunnel tissue that might be growing back, I don’t force it at all, just rotate ever so slightly.
Those pressures were driving me nuts and I felt like giving up but with some sage advice from this forum I kept going! So keep at it, it is definitely worth the effort, no more wondering where to place those cannulas up and down the arm.
Cheers 8)