Hemodialysis is one of the most widely recommended therapies for patients with renal failure. It involves using equipment that acts as the patient’s artificial kidney (dialyzer), where blood is shunted from the body to be filtered. The filtration also consists of using a dialysate solution that removes toxins from the blood that the kidney could not eliminate. The filtered blood is then returned to the body via venous circulation.
The procedure usually lasts for 2 to 4 hours, with sessions twice or thrice per week, depending on patient needs. Dialysis may be done either on an outpatient basis or as inpatient therapy. In some cases, it can also happen at home under the supervision of a properly trained health professional.
Because of the complexities involved in the care of hemodialysis patients, nurses must be trained appropriately and accredited as renal nurses before practicing. The assessment must be thorough in identifying current and potential nursing problems and protecting the patient who is already immunocompromised from the complications of his condition, which requires him to undergo dialysis, the procedure itself, or both.
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
Risk for fluid volume deficit related to excessive fluid losses secondary to hemodialysis treatment
Risk for fluid volume excess related to decreased urine output and water and sodium retention secondary to end-stage renal disease
Risk for fluid volume excess related to a rapid infusion rate of IV fluids and/or dialysate
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
Risk for fluid volume excess related to decreased urine output and water and sodium retention secondary to end-stage renal disease
Risk for fluid volume excess related to a rapid infusion rate of IV fluids and/or dialysate
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.
|
These values help determine the effectiveness of the treatment, the need for fluid and diet restrictions, and the timing of future dialysis sessions.
|
| 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
Risk for infection related to vulnerability to invasion and multiplication of myorganisms secondary to fistula/venous access devices.
Risk for infection related to suppressed inflammatory response; malnutrition; chronic disease
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. |
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.).
- Herdman, T., & Kamitsuru, S. (2018). NANDA International, Inc. nursing diagnoses (11th ed.).
- Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-
- Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier.
- McCance, K.L. & Huether, S.E. (2017). Understanding Pathophysiology: The Biologic Basis for Disease in Adults and Children (6th ed.). St. Louis: Elsevier/Mosby.
