Hemodialysis is a vital and widely recommended treatment for individuals with severe kidney problems or renal failure. It functions as an artificial kidney, using a machine called a dialyzer to cleanse the blood by removing waste and extra fluids that healthy kidneys would typically filter out. The procedure involves the blood being shunted from the body to the dialyzer, where it is filtered with the help of a dialysate solution that eliminates toxins. The filtered blood is then returned to the body through venous circulation. Each hemodialysis session usually lasts between 2 to 4 hours and is conducted two to three times a week, based on the patient’s needs. Patients can undergo hemodialysis in clinics, hospitals, or even at home with proper training and supervision.
Caring for patients undergoing hemodialysis is complex, which necessitates specialized training for nurses, who play a crucial role in ensuring patient safety and comfort. Their responsibilities include monitoring vital signs, identifying potential complications, and providing thorough patient assessments to detect current and potential nursing problems. Nurses must also safeguard immunocompromised patients from complications that could arise from their condition or the hemodialysis process itself. Additionally, educating patients and their families about what to expect during and after treatment is essential for promoting understanding and improving overall outcomes.
This knowledge is vital for both experienced nurses and nursing students as it not only enhances patient health and safety but also helps build essential skills for their professional development. Understanding how to care for hemodialysis patients equips nurses with the expertise to create comprehensive nursing care plans, ensuring they provide the best possible support and care. This foundational knowledge contributes significantly to a nurse’s ability to deliver high-quality, patient-centered care throughout their careers.
Hemodialysis Nursing Care Plan
Nurses must also remember that apart from a complete physical assessment of the patient prior to dialysis, there is also a need to conduct a focused assessment on the access sites for dialysis (fistulas, shunts, etc.) and include the psychosocial domain of the patient as well.
Actual nursing problems take utmost priority in providing care, while careful attention should also be given to addressing potential problems so that these can be avoided. Common risk nursing diagnoses for patients undergoing hemodialysis include, but are not limited to:
- Risk for fluid volume excess/deficit
- Risk for infection
- Risk for vascular trauma
Risk for Fluid Volume Deficit
During hemodialysis, excess fluid is removed from the blood through a process called ultrafiltration. If too much fluid is taken out during a session, it can lead to dehydration or hypovolemia, which is a state of decreased blood volume. This can cause symptoms such as low blood pressure, dizziness, and fainting. In addition, patients on hemodialysis also often have strict fluid intake limits to prevent fluid overload between sessions. This restriction can lead to insufficient fluid intake, especially if patients struggle to adhere to their prescribed limits. If they do not drink enough fluids, they may experience dehydration
Note: “evidenced by” is not usually applicable for a risk diagnosis since the presence of signs and symptoms already makes the nursing problem an actual diagnosis.
Desired outcomes
After the nursing interventions, the patient is expected to:
- Establish fluid balance within the normal range
- Adhere to interventions aimed to help maintain acceptable fluid balance
| Nursing Action | Rationale |
| Assess and document vital signs, weight, and vascular access site condition.
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During dialysis, rapid fluid and solute removal may lead to orthostatic hypotension, cardiopulmonary changes, and weight loss.
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| Ensure that daily weights are taken each day simultaneously, with the patient wearing the same type of clothing.
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Weight changes are an effective indicator of fluid volume. Ensuring similar conditions are present when weighing the patient helps reduce the possibility of fluctuations in weight-related to food or fluid intake before or after weights have been taken. |
| Monitor BUN, serum creatinine, serum electrolyte, and hematocrit levels between dialysis treatments.
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These values help determine the effectiveness of the treatment, the need for fluid and diet restrictions, and the timing of future dialysis sessions.
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| Ensure fluid intake within the recommended volume. | This helps ensure that the patient receives appropriate amounts of fluids, keeping him adequately hydrated and eliminating the risk for excessive fluid intake, which may cause congestion later on. |
| Assess for dialysis disequilibrium syndrome, with headache, nausea and vomiting, altered level of consciousness, and hypertension. | Rapid changes in BUN, pH, and electrolyte levels during dialysis may lead to cerebral edema and increased intracranial pressure.
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| Assess for other adverse responses to dialysis, such as dehydration, nausea, and vomiting, muscle cramps, or seizure activity. Treat as ordered. | Excess fluid removal and rapid changes in electrolyte balance can cause the fluid deficit, nausea, vomiting, and seizure activity. |
Risk for Fluid Volume Excess
Between dialysis sessions, patients often retain fluid due to the kidneys’ inability to remove excess water and waste. This can lead to significant weight gain, which indicates fluid accumulation. Many patients may gain more weight than is safe, increasing the risk of fluid overload by the time they return for their next treatment. Also, the dialysate used in hemodialysis may contain higher concentrations of sodium, especially if not carefully monitored. Increased sodium levels can cause the body to retain more water, contributing to fluid overload. So, if patients consume high-sodium diets, this can exacerbate the problem.
Note: “evidenced by” is not usually applicable for a risk diagnosis since the presence of signs and symptoms already makes the nursing problem an actual diagnosis.
Desired outcomes
After the nursing interventions, the patient is expected to:
- Establish fluid balance within the normal range
- Adhere to interventions aimed to help maintain acceptable fluid balance
| Nursing Action | Rationale |
| Assess and document vital signs, weight, and vascular access site condition.
|
Rapid fluid and solute removal during dialysis may lead to orthostatic hypotension, cardiopulmonary changes, and weight loss.
|
| Ensure that daily weights are taken at the same time each day, with the patient wearing the same type of clothing.
|
Weight changes are an effective indicator of fluid volume. Ensuring similar conditions are present when weighing the patient helps reduce the possibility of fluctuations in weight-related to food or fluid intake prior to or after weights have been taken. |
| Note presence of peripheral/sacral edema, respiratory rales, dyspnea, orthopnea, distended neck veins, ECG changes indicative of ventricular hypertrophy. | Fluid volume excess due to inefficient dialysis or repeated hypervolemia between dialysis treatments may cause/exacerbate HF, as indicated by signs/symptoms of respiratory and/or systemic venous congestion. |
| Monitor BUN, serum creatinine, serum electrolyte, and hematocrit levels between dialysis treatments.
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These values help determine the effectiveness of the treatment, the need for fluid and diet restrictions, and the timing of future dialysis sessions.
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| Ensure fluid intake within the recommended volume. | This helps ensure that the patient receives appropriate amounts of fluids, keeping him adequately hydrated and eliminating the risk for excessive fluid intake, which may cause congestion later on. |
| Calibrate infusion rate if the patient is with IV fluid and the flow rate of the dialysate during treatment. | This helps ensure that fluid volume excess is prevented and other complications are avoided. |
Risk for Infection
Hemodialysis requires access to the bloodstream, typically through catheters or needles. Central venous catheters (CVCs) are particularly associated with a high risk of infection because they remain in place for extended periods. These access points can become entry sites for bacteria, leading to bloodstream infections (BSIs) and other complications. In addition, patients on hemodialysis often require multiple hospital visits for treatment, increasing their exposure to healthcare-associated infections (HAIs). The environment of dialysis units, where multiple patients are treated simultaneously, can facilitate the transmission of infectious agents.
Also, the equipment used in hemodialysis, including machines and water supplies, can harbor bacteria if not properly disinfected. Contaminated devices or surfaces can contribute to the spread of infections among patients.
Note: “evidenced by” is not usually applicable for a risk diagnosis since the presence of signs and symptoms already makes the nursing problem an actual diagnosis.
Desired outcomes
After the nursing interventions, the patient is expected to:
- Keep fistula/access site free from infection
- Verbalize understanding of measures that can help reduce the risk of infections
| Nursing Action | Rationale |
| Assess vascular access site for a palpable pulsation or vibration and an audible bruit and inflammation.
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Infection and thrombus formation are the most common problems affecting the access site in hemodialysis clients.
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| Use a sterile technique in replacing bandages or providing care to the access site.
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This helps reduce the risk of infection to the access site. |
| Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all at-risk surfaces.
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Maintaining supple, moist skin is the best method of keeping the skin intact. Dry skin can lead to inflammation, excoriations, and possible infection episodes. |
| Teach patient and family the symptoms of infection that should be promptly reported to a primary medical caregiver (e.g., redness; warmth; swelling; tenderness or pain; new onset of drainage or change in drainage from the wound; increase in body temperature). | Involving the patient and his family in the care plan encourages cooperation and independent self-care. Also, teaching them reportable symptoms helps in the early detection.
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| Instruct patient and family about the need for good nutrition (especially protein) and proper rest to bolster immune function. | Proper rest and nutrition are also important in promoting immune function, reducing the risk of contracting infections. |
| Teach the patient to take antibiotics as prescribed. | Most antibiotics work best when a constant blood level is maintained; a constant blood level is maintained when medications are prescribed. Certain foods hinder the absorption of some medicines; patients should be instructed accordingly. |
Risk for Ineffective Tissue Perfusion (Renal Tissue)
During a dialysis session, a hypotension can possibly occur, and the patient might be at risk of inadequate renal perfusion which can lead to further kidney damage or complications.
Note: “evidenced by” is not usually applicable for a risk diagnosis since the presence of signs and symptoms already makes the nursing problem an actual diagnosis.
Desired outcomes
After the nursing interventions, the patient is expected to:
- Maintain adequate renal perfusion as evidenced by stable vital signs, urine output greater than 30 mL/hour, and absence of ischemic pain.
- Demonstrate understanding of the importance of fluid management and adherence to dietary restrictions.
| Nursing Action | Rationale |
| Monitor vital signs. | Measure blood pressure, heart rate, and oxygen saturation before, during, and after dialysis to detect early signs of hypotension or inadequate perfusion. |
| Assess Urine Output. | Document urine output hourly to monitor renal function and fluid balance. An hourly urine output of less than 30 ml might indicate inadequate renal tissue perfusion. |
| Educate on Fluid Management. | Instruct the patient on fluid restrictions and dietary modifications to prevent overload and support kidney function. |
| Monitor laboratory values such as BUN, creatinine, electrolytes, and urine output regularly. | Tracking these parameters helps assess the effectiveness of interventions aimed at improving renal perfusion and identifies any deterioration in kidney function early. |
| Position the patient to enhance venous return (e.g., elevate legs if appropriate). | Proper positioning can facilitate improved blood flow back to the heart, enhancing cardiac output and subsequently improving renal perfusion. |
| Administer IV Fluids as prescribed. | Fluid resuscitation can help restore intravascular volume, improving renal perfusion. This is particularly important in patients who may be experiencing hypovolemia due to fluid losses or inadequate intake. |
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis.
- Carpenito, L. (2016). Handbook of Nursing Diagnosis (15th ed.).
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- Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-
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