Hemodialysis- is a medical procedure designed to remove wastes, toxins and fluids from the blood when the kidneys have failed. It is the most common treatment for end-stage renal disease (ESRD), more commonly known as kidney failure. This process usually lasts for about four hours and a patient has to undergo such procedure three times a week. HD may be done in the hospital, outpatient dialysis center, or at home.

Two types of dialysis

  • Hemodialysis– blood is passed through an artificial kidney (hemodialyzer) to clean it.
  • Peritoneal dialysis– uses a filtering process similar to hemodialysis, but the blood is cleaned inside the body rather than in a machine. The good thing about this process is that patient can do this at home three to four times a day, provided that he/she has knowledge in using the facility.

Nursing Diagnosis: Risk for Excess Fluid Volume

Risk factors may include

  • Rapid/excessive fluid intake: IV, blood, plasma expanders, saline given to support BP during dialysis

Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

  • Maintain “dry weight” within patient’s normal range; be free of edema; have clear breath sounds and serum sodium levels within normal limits.

Hemodialysis Nursing Care Plan – Risk for Excess Fluid Volume

Nursing actions Rationale
Measure all sources of I&O. Weigh routinely. Aids in evaluating the fluid status, especially when compared with weight. Weight gain between treatments should not exceed 0.5 kg/day.
Monitor BP, pulse. Hypertension and tachycardia between hemodialysis runs may result from fluid overload and/or HF.
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.
Note changes in mentation. (Refer to CP: Renal Dialysis; ND: Thought Processes, risk for disturbed.) Fluid overload/hypervolemia may potentiate cerebral edema (disequilibrium syndrome).
Monitor serum sodium levels. Restrict sodium intake as indicated. High sodium levels are associated with fluid overload, edema, hypertension, and cardiac complications.

 

Restrict PO/IV fluid intake as indicated, spacing allowed fluids throughout a 24-hr period. The intermittent nature of hemodialysis results in fluid retention/overload between procedures and may require fluid restriction. Spacing fluids helps reduce thirst.

Nursing Diagnosis: Risk for Deficient Fluid Volume

Risk factors may include

  • Ultrafiltration
  • Fluid restrictions; actual blood loss (systemic heparinization or disconnection of the shunt)

Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

  • Maintain fluid balance as evidenced by stable/appropriate weight and vital signs, good skin turgor, moist mucous membranes, absence of bleeding.
Nursing actions Rationale
Measure all sources of I&O. Have patient keep diary. Aids in evaluating fluid status, especially when compared with weight. Note: Urine output is an inaccurate evaluation of renal function in dialysis patients. Some individuals have water output with little renal clearance of toxins, whereas others have oliguria or anuria.
Weigh daily before/after dialysis run. Weight loss over precisely measured time is a measure of ultrafiltration and fluid removal.

 

Monitor BP, pulse, and hemodynamic pressures if available during dialysis. Hypotension, tachycardia, falling hemodynamic pressures suggest volume depletion.

 

Note/ascertain whether diuretics and/or antihypertensives are to be withheld. Dialysis potentiates hypotensive effects if these drugs have been administered.
Verify continuity of shunt/access catheter. Disconnected shunt/open access permits exsanguination.
Apply external shunt dressing. Permit no puncture of shunt. Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and bleeding from site.
Place patient in a supine/Trendelenburg’s position as necessary. Maximizes venous return if hypotension occurs.
Assess for oozing or frank bleeding at access site or mucous membranes, incisions/wounds. Hematest/guaiac stools, gastric drainage. Systemic heparinization during dialysis increases clotting times and places patient at risk for bleeding, especially during the first 4 hr after procedure
Administer IV solutions (e.g., normal saline [NS])/volume expanders (e.g., albumin) during dialysis as indicated; Saline/dextrose solutions, electrolytes, and NaHCO3 may be infused in the venous side of continuous arteriovenous (CAV) hemofilter when high ultrafiltration rates are used for removal of extracellular fluid and toxic solutes. Volume expanders may be required during/following hemodialysis if sudden/marked hypotension occurs.
Blood/PRCs if needed. Destruction of RBCs (hemolysis) by mechanical dialysis, hemorrhagic losses, decreased RBC production may result in profound/progressive anemia requiring corrective action.
Reduce rate of ultrafiltration during dialysis as indicated. Reduces the amount of water being removed and may correct hypotension/hypovolemia.
Administer protamine sulfate as appropriate. May be needed to return clotting times to normal or if heparin rebound occurs (up to 16 hr after hemodialysis).

Nursing Diagnosis: Risk for Injury

Risk factors may include

  • Clotting; hemorrhage related to accidental disconnection; infection

Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

  • Maintain patent vascular access.
  • Be free of infection.
Nursing actions Rationale
Monitor internal AV shunt patency at frequent intervals:
Palpate for distal thrill;
Thrill is caused by turbulence of high-pressure arterial blood flow entering low-pressure venous system and should be palpable above venous exit site.

 

Auscultate for a bruit; Bruit is the sound caused by the turbulence of arterial blood entering venous system and should be audible by stethoscope, although may be very faint.
Note color of blood and/or obvious separation of cells and serum; Change of color from uniform medium red to dark purplish red suggests sluggish blood flow/early clotting. Separation in tubing is indicative of clotting. Very dark reddish-black blood next to clear yellow fluid indicates full clot formation.
Palpate skin around shunt for warmth. Diminished blood flow results in “coolness” of shunt.

 

Notify physician and/or initiate declotting procedure if there is evidence of loss of shunt patency Rapid intervention may save access; however, declotting must be done by experienced personnel.
Evaluate reports of pain, numbness/tingling; note extremity swelling distal to access. May indicate inadequate blood supply.
Avoid trauma to shunt; e.g., handle tubing gently, maintain cannula alignment. Limit activity of extremity. Avoid taking BP or drawing blood samples in shunt extremity. Instruct patient not to sleep on side with shunt or carry packages, books, purse on affected extremity. Decreases risk of clotting/disconnection.

 

Attach two cannula clamps to shunt dressing. Have tourniquet available. If cannulas separate, clamp the arterial cannula first, then the venous. If tubing comes out of vessel, clamp cannula that is still in place and apply direct pressure to bleeding site. Place tourniquet above site or inflate BP cuff to pressure just above patient’s systolic BP. Prevents massive blood loss while awaiting medical assistance if cannula separates or shunt is dislodged.
Assess skin around vascular access, noting redness, swelling, local warmth, exudate, tenderness. Signs of local infection, which can progress to sepsis if untreated.
Avoid contamination of access site. Use aseptic technique and masks when giving shunt care, applying/changing dressings, and when starting/completing dialysis process Prevents introduction of organisms that can cause infection.
Monitor temperature. Note presence of fever, chills, hypotension. Signs of infection/sepsis requiring prompt medical intervention.
Culture the site/obtain blood samples as indicated. Determines presence of pathogens.
Monitor PT, activated partial thromboplastin time (aPTT) as appropriate. Provides information about coagulation status, identifies treatment needs, and evaluates effectiveness.
Administer medications as indicated, e.g.:
Heparin (low-dose);
Infused on arterial side of filter to prevent clotting in the filter without systemic side effects.

 

Discuss use of acetylsalicylic acid (ASA), warfarin sodium (Coumadin) as appropriate. Ongoing low-dose anticoagulation may be useful in maintaining patency of shunt.

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